| Name |
Details [‑] |
|
test
prsb03-dataelement-10684
|
|
|
|
|
Patient demographics
prsb03-dataelement-116
|
|
|
|
|
Patient name
prsb03-dataelement-10016
|
|
|
| Id |
prsb03-dataelement-10016 (2018‑10‑31)
|
| Description |
The full name of the person. |
|
|
| Operationalization |
The legal name of the patient from the Patient Demographics Service (PDS), or the
name volunteered by the patient.
|
| Value Domain |
|
|
|
Patient preferred name
prsb03-dataelement-10017
|
|
|
| Id |
prsb03-dataelement-10017 (2018‑10‑31)
|
| Description |
The name by which a patient wishes to be addressed. |
|
|
| 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 |
|
|
|
Date of birth
prsb03-dataelement-10018
|
|
|
| Id |
prsb03-dataelement-10018 (2018‑10‑31)
|
| Description |
The date of birth of the patient. |
|
|
| 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 |
|
|
|
Gender
prsb03-dataelement-10019
|
|
|
| Id |
prsb03-dataelement-10019 (2018‑10‑31)
|
 |
There is an open issue with this item:
|
| Description |
The person's stated 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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Religion in dataset prsb03-dataelement-10875
|
|
|
Religion
prsb03-dataelement-10875
|
|
|
| Id |
prsb03-dataelement-10875 (2019‑03‑27 19:12:11)
|
| Concept inherits from |
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 |
|
|
|
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 |
|
|
|
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. |
| 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 |
|
|
|
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 |
|
|
|
Patient address
prsb03-dataelement-10026
|
|
|
| Id |
prsb03-dataelement-10026 (2018‑10‑31)
|
| Description |
Patient’s usual place of residence. |
|
|
| 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 |
|
|
|
Patient email address
prsb03-dataelement-10027
|
|
|
| Id |
prsb03-dataelement-10027 (2018‑10‑31)
|
| Description |
Email address of the patient |
|
|
| 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 |
|
|
|
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.
|
|
|
| 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 |
|
|
|
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.
|
|
|
| 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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Relevant contacts in dataset prsb03-dataelement-10773
|
|
|
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 |
|
|
|
Place of birth
prsb03-dataelement-10031
|
|
|
|
|
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 |
|
|
|
Date of death
prsb03-dataelement-10033
|
|
|
|
|
Time of death
prsb03-dataelement-10034
|
|
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Test
prsb03-dataelement-13091
|
|
|
|
|
test record entry
prsb03-dataelement-13092
|
|
|
|
|
medications heading
prsb03-dataelement-13093
|
|
|
|
|
Person demographics
prsb03-dataelement-10868
|
|
|
|
|
Person name
prsb03-dataelement-10869
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Date of birth
prsb03-dataelement-10871
|
|
|
|
|
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 |
|
|
|
Gender
prsb03-dataelement-10872
|
|
|
|
|
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 |
|
|
|
Ethnicity
prsb03-dataelement-10874
|
|
|
|
|
Religion
prsb03-dataelement-10876
|
|
|
|
|
Sex
prsb03-dataelement-10877
|
|
|
|
|
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. |
| FHIR |
Patient.identifier.nhsnumber |
|
| Relationship |
|
| Rationale |
Patient.identifier(nhsnumber) |
| Operationalization |
NHS data dictionary:-
NHS number
|
| Value Domain |
|
| Property |
|
|
|
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 |
|
|
|
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 |
|
|
|
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.
|
|
|
| Relationship |
|
|
|
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 |
|
| Value Domain |
|
| Property |
|
|
|
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 |
|
| Value Domain |
|
| Property |
|
|
|
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 |
|
| Value Domain |
|
| Property |
|
|
|
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 |
|
| Value Domain |
|
| Property |
|
|
|
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 |
|
|
|
Postcode
prsb03-dataelement-13087
|
|
|
|
|
Address type
prsb03-dataelement-13221
|
|
|
|
|
Person's contact details
prsb03-dataelement-13804
|
|
|
|
|
Preferred contact method
prsb03-dataelement-10886
|
|
|
|
|
Person's telephone number details
prsb03-dataelement-10883
|
|
|
|
|
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 |
|
|
|
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 |
|
| Example |
Home |
| Example |
Mobile |
| Example |
Temp |
| Example |
Old |
| Example |
Work |
|
|
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 |
|
|
|
Person's email address details
prsb03-dataelement-13807
|
|
|
|
|
Person's email address
prsb03-dataelement-10882
|
|
|
| Id |
prsb03-dataelement-10882 (2019‑03‑27 19:20:19)
|
| Description |
Email address of the person. |
|
|
| Relationship |
|
| Rationale |
Patient.contact.telecon.value |
| Operationalization |
NHS data dictionary :-
Contact email address
|
| Value Domain |
|
| Property |
|
|
|
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 |
|
| Example |
Home |
| Example |
Work |
| Example |
old |
|
|
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 |
|
|
|
Other contact information
prsb03-dataelement-13806
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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.
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
Date
prsb03-dataelement-11695
|
|
|
| Id |
prsb03-dataelement-11695 (2019‑05‑31 12:56:56)
|
| Concept inherits from |
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 |
|
|
|
Location
prsb03-dataelement-11696
|
|
|
|
|
Person completing record
prsb03-dataelement-11349
|
|
|
|
|
Name
prsb03-dataelement-11350
|
|
|
| Id |
prsb03-dataelement-11350 (2019‑05‑30 13:37:40)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-11351
|
|
|
| Id |
prsb03-dataelement-11351 (2019‑05‑30 13:37:40)
|
| Concept inherits from |
prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-11352
|
|
|
| Id |
prsb03-dataelement-11352 (2019‑05‑30 13:37:40)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-11353
|
|
|
|
|
Organisation
prsb03-dataelement-11354
|
|
|
|
|
Professional identifier
prsb03-dataelement-11355
|
|
|
| Id |
prsb03-dataelement-11355 (2019‑05‑30 13:37:40)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-11356
|
|
|
| Id |
prsb03-dataelement-11356 (2019‑05‑30 13:37:40)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-11357
|
|
|
| Id |
prsb03-dataelement-11357 (2019‑05‑30 13:37:40)
|
| Concept inherits from |
prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
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 |
|
|
|
Overseas visitor status
prsb03-dataelement-10908
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
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.
|
|
|
| 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 |
|
|
|
Educational establishment
prsb03-dataelement-10911
|
|
|
| Id |
prsb03-dataelement-10911 (2019‑04‑02 13:30:05)
|
| Concept inherits from |
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 |
|
|
|
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 |
|
|
|
Time of death
prsb03-dataelement-13088
|
|
|
|
|
NHS Number
prsb03-dataelement-10878
|
|
|
|
|
GP practice
prsb03-dataelement-101
|
|
|
|
|
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
|
|
|
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.
|
| FHIR |
Practitioner.name, where PractitionerRole.code=GP |
|
| Rationale |
Practitioner.name |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
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.
|
| 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 |
|
|
|
GP practice identifier
prsb03-dataelement-10001
|
|
|
| Id |
prsb03-dataelement-10001 (2018‑10‑31)
|
| Description |
The identifier of the registered GP practice. |
| FHIR |
Sliced into ODS and local identifier. PratitionerRole.organisation.identifier |
|
| Rationale |
PratitionerRole.organisation.identifier |
| Operationalization |
|
| Value Domain |
|
| Property |
|
|
|
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 |
|
|
|
About me
prsb03-dataelement-466
|
|
|
| Id |
prsb03-dataelement-466 (2018‑10‑31)
|
| Description |
About me |
Used by
|
one transaction, 0 templates, inherited 0 times |
| |
This concept is used in transaction About me (0 … 1) in scenario About me
|
|
|
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.
|
Used by
|
one transaction, 0 templates, inherited 0 times |
| |
This concept is used in transaction About me (0 … *) in scenario About me
|
|
|
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 |
|
Used by
|
one transaction, 0 templates, inherited 0 times |
| |
This concept is used in transaction About me (0 … 1) in scenario About me
|
|
|
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 |
|
Used by
|
one transaction, 0 templates, inherited 0 times |
| |
This concept is used in transaction About me (0 … 1) in scenario About me
|
|
|
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 |
|
Used by
|
one transaction, 0 templates, inherited 0 times |
| |
This concept is used in transaction About me (0 … 1) in scenario About me
|
|
|
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 |
|
Used by
|
one transaction, 0 templates, inherited 0 times |
| |
This concept is used in transaction About me (0 … 1) in scenario About me
|
|
|
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 |
|
Used by
|
one transaction, 0 templates, inherited 0 times |
| |
This concept is used in transaction About me (0 … 1) in scenario About me
|
|
|
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 |
|
Used by
|
one transaction, 0 templates, inherited 0 times |
| |
This concept is used in transaction About me (0 … 1) in scenario About me
|
|
|
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 |
|
Used by
|
one transaction, 0 templates, inherited 0 times |
| |
This concept is used in transaction About me (0 … 1) in scenario About me
|
|
|
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 |
|
Used by
|
one transaction, 0 templates, inherited 0 times |
| |
This concept is used in transaction About me (0 … 1) in scenario About me
|
|
|
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 |
|
Used by
|
one transaction, 0 templates, inherited 0 times |
| |
This concept is used in transaction About me (0 … 1) in scenario About me
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Individual requirements
prsb03-dataelement-160
|
|
|
|
|
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.
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Person completing record
prsb03-dataelement-13004
|
|
|
| Id |
prsb03-dataelement-13004 (2020‑04‑23 20:23:11) 0.1
|
| Concept inherits from |
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 |
|
|
|
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.
|
|
|
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. |
|
|
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 |
|
|
|
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 |
|
|
|
Coded value
prsb03-dataelement-13371
|
|
|
|
|
Free text
prsb03-dataelement-13372
|
|
|
|
|
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. |
|
|
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 |
|
|
|
Free text
prsb03-dataelement-13361
|
|
|
|
|
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 |
|
|
|
Name
prsb03-dataelement-11403
|
|
|
| Id |
prsb03-dataelement-11403 (2019‑05‑30 14:04:54)
|
| Concept inherits from |
prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
|
|
Role
prsb03-dataelement-11404
|
|
|
| Id |
prsb03-dataelement-11404 (2019‑05‑30 14:04:54)
|
| Concept inherits from |
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 |
|
|
|
Grade
prsb03-dataelement-11405
|
|
|
| Id |
prsb03-dataelement-11405 (2019‑05‑30 14:04:54)
|
| Concept inherits from |
prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Speciality
prsb03-dataelement-11406
|
|
|
|
|
Professional identifier
prsb03-dataelement-11407
|
|
|
| Id |
prsb03-dataelement-11407 (2019‑05‑30 14:04:54)
|
| Concept inherits from |
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 |
|
|
|
Organisation
prsb03-dataelement-11408
|
|
|
|
|
Contact details
prsb03-dataelement-11409
|
|
|
| Id |
prsb03-dataelement-11409 (2019‑05‑30 14:04:54)
|
| Concept inherits from |
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 |
|
|
|
Person completing record
prsb03-dataelement-11410
|
|
|
|
|
Name
prsb03-dataelement-11411
|
|
|
| Id |
prsb03-dataelement-11411 (2019‑05‑30 14:06:19)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-11412
|
|
|
| Id |
prsb03-dataelement-11412 (2019‑05‑30 14:06:19)
|
| Concept inherits from |
prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-11413
|
|
|
| Id |
prsb03-dataelement-11413 (2019‑05‑30 14:06:19)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-11414
|
|
|
|
|
Organisation
prsb03-dataelement-11415
|
|
|
|
|
Professional identifier
prsb03-dataelement-11416
|
|
|
| Id |
prsb03-dataelement-11416 (2019‑05‑30 14:06:19)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-11417
|
|
|
| Id |
prsb03-dataelement-11417 (2019‑05‑30 14:06:19)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-11418
|
|
|
| Id |
prsb03-dataelement-11418 (2019‑05‑30 14:06:19)
|
| Concept inherits from |
prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
Performing professional
prsb03-dataelement-11178
|
|
|
|
|
Name
prsb03-dataelement-11179
|
|
|
| Id |
prsb03-dataelement-11179 (2019‑05‑28 17:55:37)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-11180
|
|
|
| Id |
prsb03-dataelement-11180 (2019‑05‑28 17:55:37)
|
| Concept inherits from |
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 |
|
|
|
Speciality
prsb03-dataelement-11181
|
|
|
|
|
Team
prsb03-dataelement-11182
|
|
|
|
|
Organisation
prsb03-dataelement-11183
|
|
|
|
|
Contact details
prsb03-dataelement-11184
|
|
|
| Id |
prsb03-dataelement-11184 (2019‑05‑28 17:55:37)
|
| Concept inherits from |
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 |
|
|
|
Professional identifier
prsb03-dataelement-11185
|
|
|
| Id |
prsb03-dataelement-11185 (2019‑05‑28 17:55:37)
|
| Concept inherits from |
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.
|
| FHIR |
PractitionerRole.Practitioner.identifier (local) Practitioner.identifer (professional) |
|
| Value Domain |
|
|
|
Start date
prsb03-dataelement-11186
|
|
|
| Id |
prsb03-dataelement-11186 (2019‑05‑28 17:55:37)
|
| Concept inherits from |
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 |
|
|
|
End date
prsb03-dataelement-11187
|
|
|
| Id |
prsb03-dataelement-11187 (2019‑05‑28 17:55:37)
|
| Concept inherits from |
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 |
|
|
|
Professional contacts record entry
prsb03-dataelement-11188
|
|
|
| Id |
prsb03-dataelement-11188 (2019‑05‑28 17:55:37)
|
| Concept inherits from |
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 |
|
|
|
Person completing record
prsb03-dataelement-11189
|
|
|
|
|
Name
prsb03-dataelement-11190
|
|
|
| Id |
prsb03-dataelement-11190 (2019‑05‑28 17:58:01)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-11191
|
|
|
| Id |
prsb03-dataelement-11191 (2019‑05‑28 17:58:01)
|
| Concept inherits from |
prsb03-dataelement-10220 (2018‑10‑31)
|
| Description |
The role of the person completing record. |
| 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 |
|
|
|
Grade
prsb03-dataelement-11192
|
|
|
| Id |
prsb03-dataelement-11192 (2019‑05‑28 17:58:01)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-11193
|
|
|
| Id |
prsb03-dataelement-11193 (2019‑05‑28 17:58:01)
|
| Concept inherits from |
prsb03-dataelement-10222 (2018‑10‑31)
|
| Description |
The main specialty of the person completing the record. |
| FHIR |
PractitionerRole.specialty |
|
| Operationalization |
The main clinical specialty as held on the source system. |
| Value Domain |
|
|
|
Organisation
prsb03-dataelement-11194
|
|
|
| Id |
prsb03-dataelement-11194 (2019‑05‑28 17:58:01)
|
| Concept inherits from |
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 |
|
|
|
Professional identifier
prsb03-dataelement-11195
|
|
|
| Id |
prsb03-dataelement-11195 (2019‑05‑28 17:58:01)
|
| Concept inherits from |
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.
|
| FHIR |
PractitionerRole.Practitioner.identifier (local) Practitioner.identifer (professional) |
|
| Value Domain |
|
|
|
Date completed
prsb03-dataelement-11196
|
|
|
|
|
Contact details
prsb03-dataelement-11197
|
|
|
| Id |
prsb03-dataelement-11197 (2019‑05‑28 17:58:01)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Performing professional
prsb03-dataelement-11043
|
|
|
| Id |
prsb03-dataelement-11043 (2019‑05‑24 11:17:33)
|
| Description |
The performing professional identifying the requirement. |
| Relationship |
|
Used by
|
0 transactions, 0 templates, inherited 5 times |
| |
|
|
|
Name
prsb03-dataelement-11045
|
|
|
| Id |
prsb03-dataelement-11045 (2019‑05‑24 11:18:10)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited 6 times |
| |
This concept is inherited by concept
Name in dataset prsb03-dataelement-11054
This concept is inherited by concept
Name in dataset prsb03-dataelement-11073
This concept is inherited by concept
Name in dataset prsb03-dataelement-11092
This concept is inherited by concept
Name in dataset prsb03-dataelement-11111
This concept is inherited by concept
Name in dataset prsb03-dataelement-11130
This concept is inherited by concept
Name in dataset prsb03-dataelement-11149
|
|
|
Role
prsb03-dataelement-11046
|
|
|
| Id |
prsb03-dataelement-11046 (2019‑05‑24 11:18:10)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited 6 times |
| |
This concept is inherited by concept
Role in dataset prsb03-dataelement-11055
This concept is inherited by concept
Role in dataset prsb03-dataelement-11074
This concept is inherited by concept
Role in dataset prsb03-dataelement-11093
This concept is inherited by concept
Role in dataset prsb03-dataelement-11112
This concept is inherited by concept
Role in dataset prsb03-dataelement-11131
This concept is inherited by concept
Role in dataset prsb03-dataelement-11150
|
|
|
Speciality
prsb03-dataelement-11047
|
|
|
| Id |
prsb03-dataelement-11047 (2019‑05‑24 11:18:10)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited 6 times |
| |
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-11056
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-11075
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-11094
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-11113
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-11132
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-11151
|
|
|
Team
prsb03-dataelement-11048
|
|
|
| Id |
prsb03-dataelement-11048 (2019‑05‑24 11:18:10)
|
| Concept inherits from |
prsb03-dataelement-10355 (2018‑10‑31)
|
| Description |
The name of the team. |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited 6 times |
| |
This concept is inherited by concept
Team in dataset prsb03-dataelement-11057
This concept is inherited by concept
Team in dataset prsb03-dataelement-11076
This concept is inherited by concept
Team in dataset prsb03-dataelement-11095
This concept is inherited by concept
Team in dataset prsb03-dataelement-11114
This concept is inherited by concept
Team in dataset prsb03-dataelement-11133
This concept is inherited by concept
Team in dataset prsb03-dataelement-11152
|
|
|
Organisation
prsb03-dataelement-11049
|
|
|
| Id |
prsb03-dataelement-11049 (2019‑05‑24 11:18:10)
|
| Concept inherits from |
prsb03-dataelement-10356 (2018‑10‑31)
|
| Description |
The name of the organisation. |
Used by
|
0 transactions, 0 templates, inherited 6 times |
| |
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11058
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11077
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11096
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11115
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11134
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11153
|
|
|
Contact details
prsb03-dataelement-11050
|
|
|
| Id |
prsb03-dataelement-11050 (2019‑05‑24 11:18:10)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited 6 times |
| |
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11059
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11078
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11097
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11116
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11135
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11154
|
|
|
Start date
prsb03-dataelement-11051
|
|
|
| Id |
prsb03-dataelement-11051 (2019‑05‑24 11:18:10)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited 6 times |
| |
This concept is inherited by concept
Start date in dataset prsb03-dataelement-11060
This concept is inherited by concept
Start date in dataset prsb03-dataelement-11079
This concept is inherited by concept
Start date in dataset prsb03-dataelement-11098
This concept is inherited by concept
Start date in dataset prsb03-dataelement-11117
This concept is inherited by concept
Start date in dataset prsb03-dataelement-11136
This concept is inherited by concept
Start date in dataset prsb03-dataelement-11155
|
|
|
End date
prsb03-dataelement-11052
|
|
|
| Id |
prsb03-dataelement-11052 (2019‑05‑24 11:18:10)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited 6 times |
| |
This concept is inherited by concept
End date in dataset prsb03-dataelement-11061
This concept is inherited by concept
End date in dataset prsb03-dataelement-11080
This concept is inherited by concept
End date in dataset prsb03-dataelement-11099
This concept is inherited by concept
End date in dataset prsb03-dataelement-11118
This concept is inherited by concept
End date in dataset prsb03-dataelement-11137
This concept is inherited by concept
End date in dataset prsb03-dataelement-11156
|
|
|
Professional contacts record entry
prsb03-dataelement-11044
|
|
|
| Id |
prsb03-dataelement-11044 (2019‑05‑24 11:18:10)
|
| Concept inherits from |
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.
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Used by
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0 transactions, 0 templates, inherited 5 times |
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Performing professional
prsb03-dataelement-11033
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| Id |
prsb03-dataelement-11033 (2019‑05‑24 11:12:34)
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| Description |
The performing professional identifying the accessible information. |
| Relationship |
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Professional contacts record entry
prsb03-dataelement-11034
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| Id |
prsb03-dataelement-11034 (2019‑05‑24 11:13:32)
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| Concept inherits from |
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.
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Name
prsb03-dataelement-11035
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| Id |
prsb03-dataelement-11035 (2019‑05‑24 11:13:32)
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| Concept inherits from |
prsb03-dataelement-10352 (2018‑10‑31)
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| Description |
The name of the professional with responsibility for the care of the person. |
| Operationalization |
Free text |
| Value Domain |
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| Property |
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Role
prsb03-dataelement-11036
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| Id |
prsb03-dataelement-11036 (2019‑05‑24 11:13:32)
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| Concept inherits from |
prsb03-dataelement-10353 (2018‑10‑31)
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| 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
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| Operationalization |
FHIR value set : -
SDSjobrole
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| Value Domain |
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Speciality
prsb03-dataelement-11037
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Team
prsb03-dataelement-11038
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Organisation
prsb03-dataelement-11039
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Contact details
prsb03-dataelement-11040
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| Id |
prsb03-dataelement-11040 (2019‑05‑24 11:13:32)
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| Concept inherits from |
prsb03-dataelement-10357 (2018‑10‑31)
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| Description |
Contact details of the professional (e.g. telephone number, email address etc.). |
| Operationalization |
Free text |
| Value Domain |
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| Property |
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Start date
prsb03-dataelement-11041
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| Id |
prsb03-dataelement-11041 (2019‑05‑24 11:13:32)
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| Concept inherits from |
prsb03-dataelement-10358 (2018‑10‑31)
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| Description |
The start date of the professional relationship with the person. |
| Operationalization |
Date and time |
| Value Domain |
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| Property |
| Timestamp precision |
| at least day, month and year, hour and minute |
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End date
prsb03-dataelement-11042
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| Id |
prsb03-dataelement-11042 (2019‑05‑24 11:13:32)
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| Concept inherits from |
prsb03-dataelement-10359 (2018‑10‑31)
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| Description |
The end date of the professional relationship with the person. |
| Operationalization |
Date and time |
| Value Domain |
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| Property |
| Timestamp precision |
| at least day, month and year, hour and minute |
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Person completing record
prsb03-dataelement-11023
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Name
prsb03-dataelement-11024
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| Id |
prsb03-dataelement-11024 (2019‑05‑24 11:02:03)
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| Concept inherits from |
prsb03-dataelement-10219 (2018‑10‑31)
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| 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).
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| Value Domain |
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Role
prsb03-dataelement-11025
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| Id |
prsb03-dataelement-11025 (2019‑05‑24 11:02:03)
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| Concept inherits from |
prsb03-dataelement-10220 (2018‑10‑31)
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| Description |
The role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
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| 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).
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| Value Domain |
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Grade
prsb03-dataelement-11026
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| Id |
prsb03-dataelement-11026 (2019‑05‑24 11:02:03)
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| Concept inherits from |
prsb03-dataelement-10221 (2018‑10‑31)
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| 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
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| Value Domain |
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Specialty
prsb03-dataelement-11027
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| Id |
prsb03-dataelement-11027 (2019‑05‑24 11:02:03)
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| Concept inherits from |
prsb03-dataelement-10222 (2018‑10‑31)
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| Description |
The main specialty of the person completing the record. |
| FHIR |
PractitionerRole.specialty |
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| Operationalization |
The main clinical specialty as held on the source system. |
| Value Domain |
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Professional identifier
prsb03-dataelement-11028
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| Id |
prsb03-dataelement-11028 (2019‑05‑24 11:02:03)
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| Concept inherits from |
prsb03-dataelement-10223 (2018‑10‑31)
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| 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.
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| FHIR |
PractitionerRole.Practitioner.identifier (local) Practitioner.identifer (professional) |
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| Value Domain |
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Date completed
prsb03-dataelement-11029
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Contact details
prsb03-dataelement-11030
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| Id |
prsb03-dataelement-11030 (2019‑05‑24 11:02:03)
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| Concept inherits from |
prsb03-dataelement-10225 (2018‑10‑31)
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| 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.
|
| FHIR |
PractitionerRole.telecom |
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| 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).
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| Value Domain |
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Organisation
prsb03-dataelement-11031
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| Id |
prsb03-dataelement-11031 (2019‑05‑24 11:02:03)
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| Concept inherits from |
prsb03-dataelement-10226 (2018‑10‑31)
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| 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).
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| Value Domain |
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Accessible information - requires specific contact method
prsb03-dataelement-10063
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| Id |
prsb03-dataelement-10063 (2018‑10‑31)
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| Description |
The contact method the person requires in order for information to be accessible. |
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Date
prsb03-dataelement-11699
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| Id |
prsb03-dataelement-11699 (2019‑05‑31 13:00:44)
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| Description |
The date the accessible information requirement was identified. |
| Relationship |
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| Operationalization |
Date and time |
| Value Domain |
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| Property |
| Timestamp precision |
| at least day, month and year, hour and minute |
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Location
prsb03-dataelement-11700
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| Id |
prsb03-dataelement-11700 (2019‑05‑31 13:01:11)
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| Description |
The location where the accessible information requirement was identified. |
| Relationship |
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Coded value
prsb03-dataelement-13373
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Free text
prsb03-dataelement-13374
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Requires specific contact method
prsb03-dataelement-13362
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| Id |
prsb03-dataelement-13362 (2020‑08‑06 18:39:01)
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| Description |
The contact method the person requires in order for information to be accessible. |
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Coded value
prsb03-dataelement-13363
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| Id |
prsb03-dataelement-13363 (2020‑08‑06 18:41:53)
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| 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)|
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| Value Domain |
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Free text
prsb03-dataelement-13364
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Performing professional
prsb03-dataelement-11419
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| Id |
prsb03-dataelement-11419 (2019‑05‑30 14:08:28)
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| Description |
The professional who identified the accessible information requirement. |
| Relationship |
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Name
prsb03-dataelement-11420
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| Id |
prsb03-dataelement-11420 (2019‑05‑30 14:08:48)
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| Concept inherits from |
prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
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| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
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| Property |
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Role
prsb03-dataelement-11421
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| Id |
prsb03-dataelement-11421 (2019‑05‑30 14:08:48)
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| Concept inherits from |
prsb03-dataelement-11283 (2019‑05‑30 11:58:48)
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| 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
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| Value Domain |
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Grade
prsb03-dataelement-11422
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| Id |
prsb03-dataelement-11422 (2019‑05‑30 14:08:48)
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| Concept inherits from |
prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
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| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
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| Property |
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Speciality
prsb03-dataelement-11423
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Professional identifier
prsb03-dataelement-11424
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| Id |
prsb03-dataelement-11424 (2019‑05‑30 14:08:48)
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| Concept inherits from |
prsb03-dataelement-11285 (2019‑05‑30 12:02:46)
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| 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)
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| Operationalization |
NHS data dictionary : -
Professional registration identifier
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| Value Domain |
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| Property |
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Organisation
prsb03-dataelement-11425
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Contact details
prsb03-dataelement-11426
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| Id |
prsb03-dataelement-11426 (2019‑05‑30 14:08:48)
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| Concept inherits from |
prsb03-dataelement-11287 (2019‑05‑30 12:18:13)
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| Description |
Contact details of the professional |
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary -
UK phone number
|
| Value Domain |
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| Property |
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Person completing record
prsb03-dataelement-11427
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Name
prsb03-dataelement-11428
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| Id |
prsb03-dataelement-11428 (2019‑05‑30 14:09:25)
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| Concept inherits from |
prsb03-dataelement-11290 (2019‑05‑30 12:25:39)
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| Description |
The name of the person completing the record. |
| Relationship |
|
| Rationale |
Composition.author.Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
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| Property |
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Role
prsb03-dataelement-11429
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| Id |
prsb03-dataelement-11429 (2019‑05‑30 14:09:25)
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| Concept inherits from |
prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
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Grade
prsb03-dataelement-11430
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| Id |
prsb03-dataelement-11430 (2019‑05‑30 14:09:25)
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| Concept inherits from |
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 |
|
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Specialty
prsb03-dataelement-11431
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Organisation
prsb03-dataelement-11432
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Professional identifier
prsb03-dataelement-11433
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| Id |
prsb03-dataelement-11433 (2019‑05‑30 14:09:25)
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| Concept inherits from |
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.
|
| 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 |
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| Property |
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Date completed
prsb03-dataelement-11434
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| Id |
prsb03-dataelement-11434 (2019‑05‑30 14:09:25)
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| Concept inherits from |
prsb03-dataelement-11296 (2019‑05‑30 12:25:39)
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| 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 |
|
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Contact details
prsb03-dataelement-11435
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| Id |
prsb03-dataelement-11435 (2019‑05‑30 14:09:25)
|
| Concept inherits from |
prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
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| Property |
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Performing professional
prsb03-dataelement-11198
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Name
prsb03-dataelement-11199
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| Id |
prsb03-dataelement-11199 (2019‑05‑28 18:02:55)
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| Concept inherits from |
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 |
|
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Role
prsb03-dataelement-11200
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| Id |
prsb03-dataelement-11200 (2019‑05‑28 18:02:55)
|
| Concept inherits from |
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 |
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Speciality
prsb03-dataelement-11201
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Team
prsb03-dataelement-11202
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Organisation
prsb03-dataelement-11203
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Contact details
prsb03-dataelement-11204
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| Id |
prsb03-dataelement-11204 (2019‑05‑28 18:02:55)
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| Concept inherits from |
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 |
|
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|
Professional identifier
prsb03-dataelement-11205
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| Id |
prsb03-dataelement-11205 (2019‑05‑28 18:02:55)
|
| Concept inherits from |
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.
|
| FHIR |
PractitionerRole.Practitioner.identifier (local) Practitioner.identifer (professional) |
|
| Value Domain |
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|
Start date
prsb03-dataelement-11206
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| Id |
prsb03-dataelement-11206 (2019‑05‑28 18:02:55)
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| Concept inherits from |
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 |
|
|
|
End date
prsb03-dataelement-11207
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|
| Id |
prsb03-dataelement-11207 (2019‑05‑28 18:02:55)
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| Concept inherits from |
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 |
|
|
|
Professional contacts record entry
prsb03-dataelement-11208
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|
| Id |
prsb03-dataelement-11208 (2019‑05‑28 18:02:55)
|
| Concept inherits from |
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 |
|
|
|
Person completing record
prsb03-dataelement-11209
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Name
prsb03-dataelement-11210
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| Id |
prsb03-dataelement-11210 (2019‑05‑28 18:05:50)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-11211
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|
| Id |
prsb03-dataelement-11211 (2019‑05‑28 18:05:50)
|
| Concept inherits from |
prsb03-dataelement-10220 (2018‑10‑31)
|
| Description |
The role of the person completing record. |
| 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 |
|
|
|
Grade
prsb03-dataelement-11212
|
|
|
| Id |
prsb03-dataelement-11212 (2019‑05‑28 18:05:50)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-11213
|
|
|
| Id |
prsb03-dataelement-11213 (2019‑05‑28 18:05:50)
|
| Concept inherits from |
prsb03-dataelement-10222 (2018‑10‑31)
|
| Description |
The main specialty of the person completing the record. |
| FHIR |
PractitionerRole.specialty |
|
| Operationalization |
The main clinical specialty as held on the source system. |
| Value Domain |
|
|
|
Organisation
prsb03-dataelement-11214
|
|
|
| Id |
prsb03-dataelement-11214 (2019‑05‑28 18:05:50)
|
| Concept inherits from |
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 |
|
|
|
Professional identifier
prsb03-dataelement-11215
|
|
|
| Id |
prsb03-dataelement-11215 (2019‑05‑28 18:05:50)
|
| Concept inherits from |
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.
|
| FHIR |
PractitionerRole.Practitioner.identifier (local) Practitioner.identifer (professional) |
|
| Value Domain |
|
|
|
Date completed
prsb03-dataelement-11216
|
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Contact details
prsb03-dataelement-11217
|
|
|
| Id |
prsb03-dataelement-11217 (2019‑05‑28 18:05:50)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Performing professional
prsb03-dataelement-11053
|
|
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Name
prsb03-dataelement-11054
|
|
|
| Id |
prsb03-dataelement-11054 (2019‑05‑24 11:28:02)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-11055
|
|
|
| Id |
prsb03-dataelement-11055 (2019‑05‑24 11:28:02)
|
| Concept inherits from |
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 |
|
|
|
Speciality
prsb03-dataelement-11056
|
|
|
|
|
Team
prsb03-dataelement-11057
|
|
|
|
|
Organisation
prsb03-dataelement-11058
|
|
|
|
|
Contact details
prsb03-dataelement-11059
|
|
|
| Id |
prsb03-dataelement-11059 (2019‑05‑24 11:28:02)
|
| Concept inherits from |
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 |
|
|
|
Start date
prsb03-dataelement-11060
|
|
|
| Id |
prsb03-dataelement-11060 (2019‑05‑24 11:28:02)
|
| Concept inherits from |
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 |
|
|
|
End date
prsb03-dataelement-11061
|
|
|
| Id |
prsb03-dataelement-11061 (2019‑05‑24 11:28:02)
|
| Concept inherits from |
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 |
|
|
|
Professional contacts record entry
prsb03-dataelement-11062
|
|
|
| Id |
prsb03-dataelement-11062 (2019‑05‑24 11:28:02)
|
| Concept inherits from |
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.
|
|
|
Person completing record
prsb03-dataelement-11063
|
|
|
|
|
Name
prsb03-dataelement-11064
|
|
|
| Id |
prsb03-dataelement-11064 (2019‑05‑24 11:28:43)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-11065
|
|
|
| Id |
prsb03-dataelement-11065 (2019‑05‑24 11:28:43)
|
| Concept inherits from |
prsb03-dataelement-10220 (2018‑10‑31)
|
| Description |
The role of the person completing record. |
| 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 |
|
|
|
Grade
prsb03-dataelement-11066
|
|
|
| Id |
prsb03-dataelement-11066 (2019‑05‑24 11:28:43)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-11067
|
|
|
| Id |
prsb03-dataelement-11067 (2019‑05‑24 11:28:43)
|
| Concept inherits from |
prsb03-dataelement-10222 (2018‑10‑31)
|
| Description |
The main specialty of the person completing the record. |
| FHIR |
PractitionerRole.specialty |
|
| Operationalization |
The main clinical specialty as held on the source system. |
| Value Domain |
|
|
|
Professional identifier
prsb03-dataelement-11068
|
|
|
| Id |
prsb03-dataelement-11068 (2019‑05‑24 11:28:43)
|
| Concept inherits from |
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.
|
| FHIR |
PractitionerRole.Practitioner.identifier (local) Practitioner.identifer (professional) |
|
| Value Domain |
|
|
|
Date completed
prsb03-dataelement-11069
|
|
|
|
|
Contact details
prsb03-dataelement-11070
|
|
|
| Id |
prsb03-dataelement-11070 (2019‑05‑24 11:28:43)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Organisation
prsb03-dataelement-11071
|
|
|
| Id |
prsb03-dataelement-11071 (2019‑05‑24 11:28:43)
|
| Concept inherits from |
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 |
|
|
|
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. |
|
|
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 |
|
|
|
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 |
|
|
|
Coded value
prsb03-dataelement-13375
|
|
|
|
|
Free text
prsb03-dataelement-13376
|
|
|
|
|
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. |
|
|
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 |
|
|
|
Free text
prsb03-dataelement-13367
|
|
|
|
|
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 |
|
|
|
Name
prsb03-dataelement-11437
|
|
|
| Id |
prsb03-dataelement-11437 (2019‑05‑30 14:18:52)
|
| Concept inherits from |
prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
|
|
Role
prsb03-dataelement-11438
|
|
|
| Id |
prsb03-dataelement-11438 (2019‑05‑30 14:18:52)
|
| Concept inherits from |
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 |
|
|
|
Grade
prsb03-dataelement-11439
|
|
|
| Id |
prsb03-dataelement-11439 (2019‑05‑30 14:18:52)
|
| Concept inherits from |
prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Speciality
prsb03-dataelement-11440
|
|
|
|
|
Professional identifier
prsb03-dataelement-11441
|
|
|
| Id |
prsb03-dataelement-11441 (2019‑05‑30 14:18:52)
|
| Concept inherits from |
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 |
|
|
|
Organisation
prsb03-dataelement-11442
|
|
|
|
|
Contact details
prsb03-dataelement-11443
|
|
|
| Id |
prsb03-dataelement-11443 (2019‑05‑30 14:18:52)
|
| Concept inherits from |
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 |
|
|
|
Person completing record
prsb03-dataelement-11444
|
|
|
|
|
Name
prsb03-dataelement-11445
|
|
|
| Id |
prsb03-dataelement-11445 (2019‑05‑30 14:19:57)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-11446
|
|
|
| Id |
prsb03-dataelement-11446 (2019‑05‑30 14:19:57)
|
| Concept inherits from |
prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-11447
|
|
|
| Id |
prsb03-dataelement-11447 (2019‑05‑30 14:19:57)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-11448
|
|
|
|
|
Organisation
prsb03-dataelement-11449
|
|
|
|
|
Professional identifier
prsb03-dataelement-11450
|
|
|
| Id |
prsb03-dataelement-11450 (2019‑05‑30 14:19:57)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-11451
|
|
|
| Id |
prsb03-dataelement-11451 (2019‑05‑30 14:19:57)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-11452
|
|
|
| Id |
prsb03-dataelement-11452 (2019‑05‑30 14:19:57)
|
| Concept inherits from |
prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
Performing professional
prsb03-dataelement-11218
|
|
|
|
|
Name
prsb03-dataelement-11219
|
|
|
| Id |
prsb03-dataelement-11219 (2019‑05‑28 18:11:38)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-11220
|
|
|
| Id |
prsb03-dataelement-11220 (2019‑05‑28 18:11:38)
|
| Concept inherits from |
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 |
|
|
|
Speciality
prsb03-dataelement-11221
|
|
|
|
|
Team
prsb03-dataelement-11222
|
|
|
|
|
Organisation
prsb03-dataelement-11223
|
|
|
|
|
Contact details
prsb03-dataelement-11224
|
|
|
| Id |
prsb03-dataelement-11224 (2019‑05‑28 18:11:38)
|
| Concept inherits from |
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 |
|
|
|
Professional identifier
prsb03-dataelement-11225
|
|
|
| Id |
prsb03-dataelement-11225 (2019‑05‑28 18:11:38)
|
| Concept inherits from |
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.
|
| FHIR |
PractitionerRole.Practitioner.identifier (local) Practitioner.identifer (professional) |
|
| Value Domain |
|
|
|
Start date
prsb03-dataelement-11226
|
|
|
| Id |
prsb03-dataelement-11226 (2019‑05‑28 18:11:38)
|
| Concept inherits from |
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 |
|
|
|
End date
prsb03-dataelement-11227
|
|
|
| Id |
prsb03-dataelement-11227 (2019‑05‑28 18:11:38)
|
| Concept inherits from |
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 |
|
|
|
Professional contacts record entry
prsb03-dataelement-11228
|
|
|
| Id |
prsb03-dataelement-11228 (2019‑05‑28 18:11:38)
|
| Concept inherits from |
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 |
|
|
|
Person completing record
prsb03-dataelement-11229
|
|
|
|
|
Name
prsb03-dataelement-11230
|
|
|
| Id |
prsb03-dataelement-11230 (2019‑05‑28 18:13:47)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-11231
|
|
|
| Id |
prsb03-dataelement-11231 (2019‑05‑28 18:13:47)
|
| Concept inherits from |
prsb03-dataelement-10220 (2018‑10‑31)
|
| Description |
The role of the person completing record. |
| 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 |
|
|
|
Grade
prsb03-dataelement-11232
|
|
|
| Id |
prsb03-dataelement-11232 (2019‑05‑28 18:13:47)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-11233
|
|
|
| Id |
prsb03-dataelement-11233 (2019‑05‑28 18:13:47)
|
| Concept inherits from |
prsb03-dataelement-10222 (2018‑10‑31)
|
| Description |
The main specialty of the person completing the record. |
| FHIR |
PractitionerRole.specialty |
|
| Operationalization |
The main clinical specialty as held on the source system. |
| Value Domain |
|
|
|
Organisation
prsb03-dataelement-11234
|
|
|
| Id |
prsb03-dataelement-11234 (2019‑05‑28 18:13:47)
|
| Concept inherits from |
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 |
|
|
|
Professional identifier
prsb03-dataelement-11235
|
|
|
| Id |
prsb03-dataelement-11235 (2019‑05‑28 18:13:47)
|
| Concept inherits from |
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.
|
| FHIR |
PractitionerRole.Practitioner.identifier (local) Practitioner.identifer (professional) |
|
| Value Domain |
|
|
|
Date completed
prsb03-dataelement-11236
|
|
|
|
|
Contact details
prsb03-dataelement-11237
|
|
|
| Id |
prsb03-dataelement-11237 (2019‑05‑28 18:13:47)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Performing professional
prsb03-dataelement-11072
|
|
|
|
|
Name
prsb03-dataelement-11073
|
|
|
| Id |
prsb03-dataelement-11073 (2019‑05‑24 11:31:26)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-11074
|
|
|
| Id |
prsb03-dataelement-11074 (2019‑05‑24 11:31:26)
|
| Concept inherits from |
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 |
|
|
|
Speciality
prsb03-dataelement-11075
|
|
|
|
|
Team
prsb03-dataelement-11076
|
|
|
|
|
Organisation
prsb03-dataelement-11077
|
|
|
|
|
Contact details
prsb03-dataelement-11078
|
|
|
| Id |
prsb03-dataelement-11078 (2019‑05‑24 11:31:26)
|
| Concept inherits from |
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 |
|
|
|
Start date
prsb03-dataelement-11079
|
|
|
| Id |
prsb03-dataelement-11079 (2019‑05‑24 11:31:26)
|
| Concept inherits from |
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 |
|
|
|
End date
prsb03-dataelement-11080
|
|
|
| Id |
prsb03-dataelement-11080 (2019‑05‑24 11:31:26)
|
| Concept inherits from |
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 |
|
|
|
Professional contacts record entry
prsb03-dataelement-11081
|
|
|
| Id |
prsb03-dataelement-11081 (2019‑05‑24 11:31:26)
|
| Concept inherits from |
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.
|
|
|
Person completing record
prsb03-dataelement-11082
|
|
|
|
|
Name
prsb03-dataelement-11083
|
|
|
| Id |
prsb03-dataelement-11083 (2019‑05‑24 11:31:54)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-11084
|
|
|
| Id |
prsb03-dataelement-11084 (2019‑05‑24 11:31:54)
|
| Concept inherits from |
prsb03-dataelement-10220 (2018‑10‑31)
|
| Description |
The role of the person completing record. |
| 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 |
|
|
|
Grade
prsb03-dataelement-11085
|
|
|
| Id |
prsb03-dataelement-11085 (2019‑05‑24 11:31:54)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-11086
|
|
|
| Id |
prsb03-dataelement-11086 (2019‑05‑24 11:31:54)
|
| Concept inherits from |
prsb03-dataelement-10222 (2018‑10‑31)
|
| Description |
The main specialty of the person completing the record. |
| FHIR |
PractitionerRole.specialty |
|
| Operationalization |
The main clinical specialty as held on the source system. |
| Value Domain |
|
|
|
Professional identifier
prsb03-dataelement-11087
|
|
|
| Id |
prsb03-dataelement-11087 (2019‑05‑24 11:31:54)
|
| Concept inherits from |
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.
|
| FHIR |
PractitionerRole.Practitioner.identifier (local) Practitioner.identifer (professional) |
|
| Value Domain |
|
|
|
Date completed
prsb03-dataelement-11088
|
|
|
|
|
Contact details
prsb03-dataelement-11089
|
|
|
| Id |
prsb03-dataelement-11089 (2019‑05‑24 11:31:54)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Organisation
prsb03-dataelement-11090
|
|
|
| Id |
prsb03-dataelement-11090 (2019‑05‑24 11:31:54)
|
| Concept inherits from |
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 |
|
|
|
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
|
|
|
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 |
|
|
|
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 |
|
|
|
Coded value
prsb03-dataelement-13377
|
|
|
|
|
Free text
prsb03-dataelement-13378
|
|
|
|
|
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.
|
|
|
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 |
|
|
|
Free text
prsb03-dataelement-13370
|
|
|
|
|
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 |
|
|
|
Name
prsb03-dataelement-11454
|
|
|
| Id |
prsb03-dataelement-11454 (2019‑05‑30 14:22:06)
|
| Concept inherits from |
prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
|
|
Role
prsb03-dataelement-11455
|
|
|
| Id |
prsb03-dataelement-11455 (2019‑05‑30 14:22:06)
|
| Concept inherits from |
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 |
|
|
|
Grade
prsb03-dataelement-11456
|
|
|
| Id |
prsb03-dataelement-11456 (2019‑05‑30 14:22:06)
|
| Concept inherits from |
prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Speciality
prsb03-dataelement-11457
|
|
|
|
|
Professional identifier
prsb03-dataelement-11458
|
|
|
| Id |
prsb03-dataelement-11458 (2019‑05‑30 14:22:06)
|
| Concept inherits from |
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 |
|
|
|
Organisation
prsb03-dataelement-11459
|
|
|
|
|
Contact details
prsb03-dataelement-11460
|
|
|
| Id |
prsb03-dataelement-11460 (2019‑05‑30 14:22:06)
|
| Concept inherits from |
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 |
|
|
|
Person completing record
prsb03-dataelement-11461
|
|
|
|
|
Name
prsb03-dataelement-11462
|
|
|
| Id |
prsb03-dataelement-11462 (2019‑05‑30 14:23:26)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-11463
|
|
|
| Id |
prsb03-dataelement-11463 (2019‑05‑30 14:23:26)
|
| Concept inherits from |
prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-11464
|
|
|
| Id |
prsb03-dataelement-11464 (2019‑05‑30 14:23:26)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-11465
|
|
|
|
|
Organisation
prsb03-dataelement-11466
|
|
|
|
|
Professional identifier
prsb03-dataelement-11467
|
|
|
| Id |
prsb03-dataelement-11467 (2019‑05‑30 14:23:26)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-11468
|
|
|
| Id |
prsb03-dataelement-11468 (2019‑05‑30 14:23:26)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-11469
|
|
|
| Id |
prsb03-dataelement-11469 (2019‑05‑30 14:23:26)
|
| Concept inherits from |
prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
Performing professional
prsb03-dataelement-11238
|
|
|
|
|
Name
prsb03-dataelement-11239
|
|
|
| Id |
prsb03-dataelement-11239 (2019‑05‑28 18:15:22)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-11240
|
|
|
| Id |
prsb03-dataelement-11240 (2019‑05‑28 18:15:22)
|
| Concept inherits from |
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 |
|
|
|
Speciality
prsb03-dataelement-11241
|
|
|
|
|
Team
prsb03-dataelement-11242
|
|
|
|
|
Organisation
prsb03-dataelement-11243
|
|
|
|
|
Contact details
prsb03-dataelement-11244
|
|
|
| Id |
prsb03-dataelement-11244 (2019‑05‑28 18:15:22)
|
| Concept inherits from |
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 |
|
|
|
Professional identifier
prsb03-dataelement-11245
|
|
|
| Id |
prsb03-dataelement-11245 (2019‑05‑28 18:15:22)
|
| Concept inherits from |
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.
|
| FHIR |
PractitionerRole.Practitioner.identifier (local) Practitioner.identifer (professional) |
|
| Value Domain |
|
|
|
Start date
prsb03-dataelement-11246
|
|
|
| Id |
prsb03-dataelement-11246 (2019‑05‑28 18:15:22)
|
| Concept inherits from |
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 |
|
|
|
End date
prsb03-dataelement-11247
|
|
|
| Id |
prsb03-dataelement-11247 (2019‑05‑28 18:15:22)
|
| Concept inherits from |
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 |
|
|
|
Professional contacts record entry
prsb03-dataelement-11248
|
|
|
| Id |
prsb03-dataelement-11248 (2019‑05‑28 18:15:22)
|
| Concept inherits from |
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 |
|
|
|
Person completing record
prsb03-dataelement-11249
|
|
|
|
|
Name
prsb03-dataelement-11250
|
|
|
| Id |
prsb03-dataelement-11250 (2019‑05‑28 18:17:17)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-11251
|
|
|
| Id |
prsb03-dataelement-11251 (2019‑05‑28 18:17:17)
|
| Concept inherits from |
prsb03-dataelement-10220 (2018‑10‑31)
|
| Description |
The role of the person completing record. |
| 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 |
|
|
|
Grade
prsb03-dataelement-11252
|
|
|
| Id |
prsb03-dataelement-11252 (2019‑05‑28 18:17:17)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-11253
|
|
|
| Id |
prsb03-dataelement-11253 (2019‑05‑28 18:17:17)
|
| Concept inherits from |
prsb03-dataelement-10222 (2018‑10‑31)
|
| Description |
The main specialty of the person completing the record. |
| FHIR |
PractitionerRole.specialty |
|
| Operationalization |
The main clinical specialty as held on the source system. |
| Value Domain |
|
|
|
Organisation
prsb03-dataelement-11254
|
|
|
| Id |
prsb03-dataelement-11254 (2019‑05‑28 18:17:17)
|
| Concept inherits from |
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 |
|
|
|
Professional identifier
prsb03-dataelement-11255
|
|
|
| Id |
prsb03-dataelement-11255 (2019‑05‑28 18:17:17)
|
| Concept inherits from |
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.
|
| FHIR |
PractitionerRole.Practitioner.identifier (local) Practitioner.identifer (professional) |
|
| Value Domain |
|
|
|
Date completed
prsb03-dataelement-11256
|
|
|
|
|
Contact details
prsb03-dataelement-11257
|
|
|
| Id |
prsb03-dataelement-11257 (2019‑05‑28 18:17:17)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Performing professional
prsb03-dataelement-11091
|
|
|
|
|
Name
prsb03-dataelement-11092
|
|
|
| Id |
prsb03-dataelement-11092 (2019‑05‑24 11:33:21)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-11093
|
|
|
| Id |
prsb03-dataelement-11093 (2019‑05‑24 11:33:21)
|
| Concept inherits from |
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 |
|
|
|
Speciality
prsb03-dataelement-11094
|
|
|
|
|
Team
prsb03-dataelement-11095
|
|
|
|
|
Organisation
prsb03-dataelement-11096
|
|
|
|
|
Contact details
prsb03-dataelement-11097
|
|
|
| Id |
prsb03-dataelement-11097 (2019‑05‑24 11:33:21)
|
| Concept inherits from |
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 |
|
|
|
Start date
prsb03-dataelement-11098
|
|
|
| Id |
prsb03-dataelement-11098 (2019‑05‑24 11:33:21)
|
| Concept inherits from |
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 |
|
|
|
End date
prsb03-dataelement-11099
|
|
|
| Id |
prsb03-dataelement-11099 (2019‑05‑24 11:33:21)
|
| Concept inherits from |
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 |
|
|
|
Professional contacts record entry
prsb03-dataelement-11100
|
|
|
| Id |
prsb03-dataelement-11100 (2019‑05‑24 11:33:21)
|
| Concept inherits from |
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.
|
|
|
Person completing record
prsb03-dataelement-11101
|
|
|
|
|
Name
prsb03-dataelement-11102
|
|
|
| Id |
prsb03-dataelement-11102 (2019‑05‑24 11:33:56)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-11103
|
|
|
| Id |
prsb03-dataelement-11103 (2019‑05‑24 11:33:56)
|
| Concept inherits from |
prsb03-dataelement-10220 (2018‑10‑31)
|
| Description |
The role of the person completing record. |
| 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 |
|
|
|
Grade
prsb03-dataelement-11104
|
|
|
| Id |
prsb03-dataelement-11104 (2019‑05‑24 11:33:56)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-11105
|
|
|
| Id |
prsb03-dataelement-11105 (2019‑05‑24 11:33:56)
|
| Concept inherits from |
prsb03-dataelement-10222 (2018‑10‑31)
|
| Description |
The main specialty of the person completing the record. |
| FHIR |
PractitionerRole.specialty |
|
| Operationalization |
The main clinical specialty as held on the source system. |
| Value Domain |
|
|
|
Professional identifier
prsb03-dataelement-11106
|
|
|
| Id |
prsb03-dataelement-11106 (2019‑05‑24 11:33:56)
|
| Concept inherits from |
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.
|
| FHIR |
PractitionerRole.Practitioner.identifier (local) Practitioner.identifer (professional) |
|
| Value Domain |
|
|
|
Date completed
prsb03-dataelement-11107
|
|
|
|
|
Contact details
prsb03-dataelement-11108
|
|
|
| Id |
prsb03-dataelement-11108 (2019‑05‑24 11:33:56)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Organisation
prsb03-dataelement-11109
|
|
|
| Id |
prsb03-dataelement-11109 (2019‑05‑24 11:33:56)
|
| Concept inherits from |
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 |
|
|
|
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.
|
|
|
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
|
|
|
Location
prsb03-dataelement-13098
|
|
|
| Id |
prsb03-dataelement-13098 (2020‑06‑24 11:17:33)
|
| Description |
The location where the reasonable adjustment was identified. |
|
|
Coded value
prsb03-dataelement-13357
|
|
|
|
|
Free text
prsb03-dataelement-13358
|
|
|
|
|
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 |
|
|
|
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
|
|
|
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 |
|
|
|
Free text
prsb03-dataelement-13506
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Name
prsb03-dataelement-13028
|
|
|
| Id |
prsb03-dataelement-13028 (2020‑04‑28 19:31:24)
|
| Concept inherits from |
prsb03-dataelement-12185 (2019‑05‑31 16:19:35)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
|
|
Role
prsb03-dataelement-13029
|
|
|
|
|
Grade
prsb03-dataelement-13030
|
|
|
| Id |
prsb03-dataelement-13030 (2020‑04‑28 19:31:24)
|
| Concept inherits from |
prsb03-dataelement-12187 (2019‑05‑31 16:19:35)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Speciality
prsb03-dataelement-13031
|
|
|
|
|
Professional identifier
prsb03-dataelement-13032
|
|
|
| Id |
prsb03-dataelement-13032 (2020‑04‑28 19:31:24)
|
| Concept inherits from |
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 |
|
|
|
Organisation
prsb03-dataelement-13033
|
|
|
|
|
Contact details
prsb03-dataelement-13034
|
|
|
| Id |
prsb03-dataelement-13034 (2020‑04‑28 19:31:24)
|
| Concept inherits from |
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 |
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Name
prsb03-dataelement-13036
|
|
|
| Id |
prsb03-dataelement-13036 (2020‑04‑28 19:33:40)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited 3 times |
| |
This concept is inherited by concept
Name in dataset prsb03-dataelement-13321
This concept is inherited by concept
Name in dataset prsb03-dataelement-13606
This concept is inherited by concept
Name in dataset prsb03-dataelement-13101
|
|
|
Role
prsb03-dataelement-13037
|
|
|
| Id |
prsb03-dataelement-13037 (2020‑04‑28 19:33:40)
|
| Concept inherits from |
prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
Used by
|
0 transactions, 0 templates, inherited 3 times |
| |
This concept is inherited by concept
Role in dataset prsb03-dataelement-13322
This concept is inherited by concept
Role in dataset prsb03-dataelement-13607
This concept is inherited by concept
Role in dataset prsb03-dataelement-13102
|
|
|
Grade
prsb03-dataelement-13038
|
|
|
| Id |
prsb03-dataelement-13038 (2020‑04‑28 19:33:40)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited 3 times |
| |
This concept is inherited by concept
Grade in dataset prsb03-dataelement-13323
This concept is inherited by concept
Grade in dataset prsb03-dataelement-13608
This concept is inherited by concept
Grade in dataset prsb03-dataelement-13103
|
|
|
Specialty
prsb03-dataelement-13039
|
|
|
| Id |
prsb03-dataelement-13039 (2020‑04‑28 19:33:40)
|
| Concept inherits from |
prsb03-dataelement-11293 (2019‑05‑30 12:25:39)
|
| Description |
The main specialty of the person completing the record. |
| FHIR |
PractitionerRole.specialty |
|
| Relationship |
|
| Rationale |
PractitionerRole.speciality |
| Operationalization |
NHS data dictionary :-
Activity treatment function code
|
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited 3 times |
| |
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-13324
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-13609
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-13104
|
|
|
Organisation
prsb03-dataelement-13040
|
|
|
| Id |
prsb03-dataelement-13040 (2020‑04‑28 19:33:40)
|
| Concept inherits from |
prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
|
| Description |
The organisation the person completing the record works for. |
| Relationship |
|
Used by
|
0 transactions, 0 templates, inherited 3 times |
| |
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-13325
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-13610
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-13105
|
|
|
Professional identifier
prsb03-dataelement-13041
|
|
|
| Id |
prsb03-dataelement-13041 (2020‑04‑28 19:33:40)
|
| Concept inherits from |
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.
|
| 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 |
|
Used by
|
0 transactions, 0 templates, inherited 3 times |
| |
|
|
|
Date completed
prsb03-dataelement-13042
|
|
|
| Id |
prsb03-dataelement-13042 (2020‑04‑28 19:33:40)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited 3 times |
| |
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-13327
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-13612
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-13107
|
|
|
Contact details
prsb03-dataelement-13043
|
|
|
| Id |
prsb03-dataelement-13043 (2020‑04‑28 19:33:40)
|
| Concept inherits from |
prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited 3 times |
| |
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-13328
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-13613
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-13108
|
|
|
Performing Professional
prsb03-dataelement-13026
|
|
|
|
|
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 |
|
|
|
Person completing record
prsb03-dataelement-13019
|
|
|
| Id |
prsb03-dataelement-13019 (2020‑04‑28 19:13:17) 0.2
|
| Concept inherits from |
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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. |
|
|
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
|
|
|
Location
prsb03-dataelement-13099
|
|
|
|
|
Coded value
prsb03-dataelement-13429
|
|
|
|
|
Free text
prsb03-dataelement-13430
|
|
|
|
|
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
|
|
|
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 |
|
|
|
Free text
prsb03-dataelement-13508
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
Performing professional
prsb03-dataelement-13044
|
|
|
| Id |
prsb03-dataelement-13044 (2020‑04‑28 19:34:59)
|
| Description |
The professional who confirmed the impairment. |
| Relationship |
|
|
|
Name
prsb03-dataelement-13045
|
|
|
| Id |
prsb03-dataelement-13045 (2020‑04‑28 19:35:28)
|
| Concept inherits from |
prsb03-dataelement-12028 (2019‑05‑31 15:30:50)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
|
|
Role
prsb03-dataelement-13046
|
|
|
| Id |
prsb03-dataelement-13046 (2020‑04‑28 19:35:28)
|
| Concept inherits from |
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 |
|
|
|
Grade
prsb03-dataelement-13047
|
|
|
| Id |
prsb03-dataelement-13047 (2020‑04‑28 19:35:28)
|
| Concept inherits from |
prsb03-dataelement-12030 (2019‑05‑31 15:30:50)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Speciality
prsb03-dataelement-13048
|
|
|
|
|
Professional identifier
prsb03-dataelement-13049
|
|
|
| Id |
prsb03-dataelement-13049 (2020‑04‑28 19:35:28)
|
| Concept inherits from |
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 |
|
|
|
Organisation
prsb03-dataelement-13050
|
|
|
|
|
Contact details
prsb03-dataelement-13051
|
|
|
| Id |
prsb03-dataelement-13051 (2020‑04‑28 19:35:28)
|
| Concept inherits from |
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 |
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Name
prsb03-dataelement-13053
|
|
|
| Id |
prsb03-dataelement-13053 (2020‑04‑28 19:36:38)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
This concept is inherited by concept
Name in dataset prsb03-dataelement-13493
This concept is inherited by concept
Name in dataset prsb03-dataelement-13741
|
|
|
Role
prsb03-dataelement-13054
|
|
|
| Id |
prsb03-dataelement-13054 (2020‑04‑28 19:36:38)
|
| Concept inherits from |
prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
This concept is inherited by concept
Role in dataset prsb03-dataelement-13494
This concept is inherited by concept
Role in dataset prsb03-dataelement-13742
|
|
|
Grade
prsb03-dataelement-13055
|
|
|
| Id |
prsb03-dataelement-13055 (2020‑04‑28 19:36:38)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
This concept is inherited by concept
Grade in dataset prsb03-dataelement-13495
This concept is inherited by concept
Grade in dataset prsb03-dataelement-13743
|
|
|
Specialty
prsb03-dataelement-13056
|
|
|
| Id |
prsb03-dataelement-13056 (2020‑04‑28 19:36:38)
|
| Concept inherits from |
prsb03-dataelement-11293 (2019‑05‑30 12:25:39)
|
| Description |
The main specialty of the person completing the record. |
| FHIR |
PractitionerRole.specialty |
|
| Relationship |
|
| Rationale |
PractitionerRole.speciality |
| Operationalization |
NHS data dictionary :-
Activity treatment function code
|
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-13496
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-13744
|
|
|
Organisation
prsb03-dataelement-13057
|
|
|
| Id |
prsb03-dataelement-13057 (2020‑04‑28 19:36:38)
|
| Concept inherits from |
prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
|
| Description |
The organisation the person completing the record works for. |
| Relationship |
|
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-13497
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-13745
|
|
|
Professional identifier
prsb03-dataelement-13058
|
|
|
| Id |
prsb03-dataelement-13058 (2020‑04‑28 19:36:38)
|
| Concept inherits from |
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.
|
| 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 |
|
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
|
|
|
Date completed
prsb03-dataelement-13059
|
|
|
| Id |
prsb03-dataelement-13059 (2020‑04‑28 19:36:38)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-13499
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-13747
|
|
|
Contact details
prsb03-dataelement-13060
|
|
|
| Id |
prsb03-dataelement-13060 (2020‑04‑28 19:36:38)
|
| Concept inherits from |
prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-13500
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-13748
|
|
|
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 |
|
|
|
Cognition
prsb03-dataelement-10066
|
|
|
|
|
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 |
|
|
|
Location
prsb03-dataelement-11706
|
|
|
| Id |
prsb03-dataelement-11706 (2019‑05‑31 13:06:37)
|
| Description |
The location where the cognitive impairment was identified. |
| Relationship |
|
|
|
Coded value
prsb03-dataelement-13431
|
|
|
|
|
Free text
prsb03-dataelement-13432
|
|
|
|
|
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 |
|
|
|
Performing professional
prsb03-dataelement-11470
|
|
|
| Id |
prsb03-dataelement-11470 (2019‑05‑30 14:25:03)
|
| Description |
The professional who identified the cognitive impairment. |
| Relationship |
|
|
|
Name
prsb03-dataelement-11471
|
|
|
| Id |
prsb03-dataelement-11471 (2019‑05‑30 14:25:24)
|
| Concept inherits from |
prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
|
|
Role
prsb03-dataelement-11472
|
|
|
| Id |
prsb03-dataelement-11472 (2019‑05‑30 14:25:24)
|
| Concept inherits from |
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 |
|
|
|
Grade
prsb03-dataelement-11473
|
|
|
| Id |
prsb03-dataelement-11473 (2019‑05‑30 14:25:24)
|
| Concept inherits from |
prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Speciality
prsb03-dataelement-11474
|
|
|
|
|
Professional identifier
prsb03-dataelement-11475
|
|
|
| Id |
prsb03-dataelement-11475 (2019‑05‑30 14:25:24)
|
| Concept inherits from |
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 |
|
|
|
Organisation
prsb03-dataelement-11476
|
|
|
|
|
Contact details
prsb03-dataelement-11477
|
|
|
| Id |
prsb03-dataelement-11477 (2019‑05‑30 14:25:24)
|
| Concept inherits from |
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 |
|
|
|
Person completing record
prsb03-dataelement-11478
|
|
|
|
|
Name
prsb03-dataelement-11479
|
|
|
| Id |
prsb03-dataelement-11479 (2019‑05‑30 14:26:05)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-11480
|
|
|
| Id |
prsb03-dataelement-11480 (2019‑05‑30 14:26:05)
|
| Concept inherits from |
prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-11481
|
|
|
| Id |
prsb03-dataelement-11481 (2019‑05‑30 14:26:05)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-11482
|
|
|
|
|
Organisation
prsb03-dataelement-11483
|
|
|
|
|
Professional identifier
prsb03-dataelement-11484
|
|
|
| Id |
prsb03-dataelement-11484 (2019‑05‑30 14:26:05)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-11485
|
|
|
| Id |
prsb03-dataelement-11485 (2019‑05‑30 14:26:05)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-11486
|
|
|
| Id |
prsb03-dataelement-11486 (2019‑05‑30 14:26:05)
|
| Concept inherits from |
prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
Performing professional
prsb03-dataelement-11110
|
|
|
|
|
Name
prsb03-dataelement-11111
|
|
|
| Id |
prsb03-dataelement-11111 (2019‑05‑24 11:38:06)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-11112
|
|
|
| Id |
prsb03-dataelement-11112 (2019‑05‑24 11:38:06)
|
| Concept inherits from |
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 |
|
|
|
Speciality
prsb03-dataelement-11113
|
|
|
|
|
Team
prsb03-dataelement-11114
|
|
|
|
|
Organisation
prsb03-dataelement-11115
|
|
|
|
|
Contact details
prsb03-dataelement-11116
|
|
|
| Id |
prsb03-dataelement-11116 (2019‑05‑24 11:38:06)
|
| Concept inherits from |
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 |
|
|
|
Start date
prsb03-dataelement-11117
|
|
|
| Id |
prsb03-dataelement-11117 (2019‑05‑24 11:38:06)
|
| Concept inherits from |
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 |
|
|
|
End date
prsb03-dataelement-11118
|
|
|
| Id |
prsb03-dataelement-11118 (2019‑05‑24 11:38:06)
|
| Concept inherits from |
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 |
|
|
|
Professional contacts record entry
prsb03-dataelement-11119
|
|
|
| Id |
prsb03-dataelement-11119 (2019‑05‑24 11:38:06)
|
| Concept inherits from |
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.
|
|
|
Person completing record
prsb03-dataelement-11120
|
|
|
|
|
Name
prsb03-dataelement-11121
|
|
|
| Id |
prsb03-dataelement-11121 (2019‑05‑24 11:38:55)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-11122
|
|
|
| Id |
prsb03-dataelement-11122 (2019‑05‑24 11:38:55)
|
| Concept inherits from |
prsb03-dataelement-10220 (2018‑10‑31)
|
| Description |
The role of the person completing record. |
| 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 |
|
|
|
Grade
prsb03-dataelement-11123
|
|
|
| Id |
prsb03-dataelement-11123 (2019‑05‑24 11:38:55)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-11124
|
|
|
| Id |
prsb03-dataelement-11124 (2019‑05‑24 11:38:55)
|
| Concept inherits from |
prsb03-dataelement-10222 (2018‑10‑31)
|
| Description |
The main specialty of the person completing the record. |
| FHIR |
PractitionerRole.specialty |
|
| Operationalization |
The main clinical specialty as held on the source system. |
| Value Domain |
|
|
|
Professional identifier
prsb03-dataelement-11125
|
|
|
| Id |
prsb03-dataelement-11125 (2019‑05‑24 11:38:55)
|
| Concept inherits from |
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.
|
| FHIR |
PractitionerRole.Practitioner.identifier (local) Practitioner.identifer (professional) |
|
| Value Domain |
|
|
|
Date completed
prsb03-dataelement-11126
|
|
|
|
|
Contact details
prsb03-dataelement-11127
|
|
|
| Id |
prsb03-dataelement-11127 (2019‑05‑24 11:38:55)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Organisation
prsb03-dataelement-11128
|
|
|
| Id |
prsb03-dataelement-11128 (2019‑05‑24 11:38:55)
|
| Concept inherits from |
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 |
|
|
|
Mobility
prsb03-dataelement-10067
|
|
|
|
|
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 |
|
|
|
Location
prsb03-dataelement-11710
|
|
|
| Id |
prsb03-dataelement-11710 (2019‑05‑31 13:11:14)
|
| Description |
The location where the mobility needs were identified. |
| Relationship |
|
|
|
Coded value
prsb03-dataelement-13433
|
|
|
|
|
Free text
prsb03-dataelement-13434
|
|
|
|
|
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.
|
|
|
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 |
|
|
|
Free text
prsb03-dataelement-13672
|
|
|
|
|
Location
prsb03-dataelement-11709
|
|
|
|
|
Location
prsb03-dataelement-11708
|
|
|
|
|
Performing professional
prsb03-dataelement-11487
|
|
|
| Id |
prsb03-dataelement-11487 (2019‑05‑30 14:26:29)
|
| Description |
The professional who identified the mobility needs. |
| Relationship |
|
|
|
Name
prsb03-dataelement-11488
|
|
|
| Id |
prsb03-dataelement-11488 (2019‑05‑30 14:27:10)
|
| Concept inherits from |
prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
|
|
Role
prsb03-dataelement-11489
|
|
|
| Id |
prsb03-dataelement-11489 (2019‑05‑30 14:27:10)
|
| Concept inherits from |
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 |
|
|
|
Grade
prsb03-dataelement-11490
|
|
|
| Id |
prsb03-dataelement-11490 (2019‑05‑30 14:27:10)
|
| Concept inherits from |
prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Speciality
prsb03-dataelement-11491
|
|
|
|
|
Professional identifier
prsb03-dataelement-11492
|
|
|
| Id |
prsb03-dataelement-11492 (2019‑05‑30 14:27:10)
|
| Concept inherits from |
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 |
|
|
|
Organisation
prsb03-dataelement-11493
|
|
|
|
|
Contact details
prsb03-dataelement-11494
|
|
|
| Id |
prsb03-dataelement-11494 (2019‑05‑30 14:27:10)
|
| Concept inherits from |
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 |
|
|
|
Person completing record
prsb03-dataelement-11495
|
|
|
|
|
Name
prsb03-dataelement-11496
|
|
|
| Id |
prsb03-dataelement-11496 (2019‑05‑30 14:27:45)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-11497
|
|
|
| Id |
prsb03-dataelement-11497 (2019‑05‑30 14:27:45)
|
| Concept inherits from |
prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-11498
|
|
|
| Id |
prsb03-dataelement-11498 (2019‑05‑30 14:27:45)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-11499
|
|
|
|
|
Organisation
prsb03-dataelement-11500
|
|
|
|
|
Professional identifier
prsb03-dataelement-11501
|
|
|
| Id |
prsb03-dataelement-11501 (2019‑05‑30 14:27:45)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-11502
|
|
|
| Id |
prsb03-dataelement-11502 (2019‑05‑30 14:27:45)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-11503
|
|
|
| Id |
prsb03-dataelement-11503 (2019‑05‑30 14:27:45)
|
| Concept inherits from |
prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
Performing professional
prsb03-dataelement-11129
|
|
|
|
|
Name
prsb03-dataelement-11130
|
|
|
| Id |
prsb03-dataelement-11130 (2019‑05‑24 11:40:41)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-11131
|
|
|
| Id |
prsb03-dataelement-11131 (2019‑05‑24 11:40:41)
|
| Concept inherits from |
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 |
|
|
|
Speciality
prsb03-dataelement-11132
|
|
|
|
|
Team
prsb03-dataelement-11133
|
|
|
|
|
Organisation
prsb03-dataelement-11134
|
|
|
|
|
Contact details
prsb03-dataelement-11135
|
|
|
| Id |
prsb03-dataelement-11135 (2019‑05‑24 11:40:41)
|
| Concept inherits from |
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 |
|
|
|
Start date
prsb03-dataelement-11136
|
|
|
| Id |
prsb03-dataelement-11136 (2019‑05‑24 11:40:41)
|
| Concept inherits from |
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 |
|
|
|
End date
prsb03-dataelement-11137
|
|
|
| Id |
prsb03-dataelement-11137 (2019‑05‑24 11:40:41)
|
| Concept inherits from |
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 |
|
|
|
Professional contacts record entry
prsb03-dataelement-11138
|
|
|
| Id |
prsb03-dataelement-11138 (2019‑05‑24 11:40:41)
|
| Concept inherits from |
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.
|
|
|
Person completing record
prsb03-dataelement-11139
|
|
|
|
|
Name
prsb03-dataelement-11140
|
|
|
| Id |
prsb03-dataelement-11140 (2019‑05‑24 11:41:23)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-11141
|
|
|
| Id |
prsb03-dataelement-11141 (2019‑05‑24 11:41:23)
|
| Concept inherits from |
prsb03-dataelement-10220 (2018‑10‑31)
|
| Description |
The role of the person completing record. |
| 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 |
|
|
|
Grade
prsb03-dataelement-11142
|
|
|
| Id |
prsb03-dataelement-11142 (2019‑05‑24 11:41:23)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-11143
|
|
|
| Id |
prsb03-dataelement-11143 (2019‑05‑24 11:41:23)
|
| Concept inherits from |
prsb03-dataelement-10222 (2018‑10‑31)
|
| Description |
The main specialty of the person completing the record. |
| FHIR |
PractitionerRole.specialty |
|
| Operationalization |
The main clinical specialty as held on the source system. |
| Value Domain |
|
|
|
Professional identifier
prsb03-dataelement-11144
|
|
|
| Id |
prsb03-dataelement-11144 (2019‑05‑24 11:41:23)
|
| Concept inherits from |
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.
|
| FHIR |
PractitionerRole.Practitioner.identifier (local) Practitioner.identifer (professional) |
|
| Value Domain |
|
|
|
Date completed
prsb03-dataelement-11145
|
|
|
|
|
Contact details
prsb03-dataelement-11146
|
|
|
| Id |
prsb03-dataelement-11146 (2019‑05‑24 11:41:23)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Organisation
prsb03-dataelement-11147
|
|
|
| Id |
prsb03-dataelement-11147 (2019‑05‑24 11:41:23)
|
| Concept inherits from |
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 |
|
|
|
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 |
|
|
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 |
|
|
|
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 |
|
|
|
Coded value
prsb03-dataelement-13435
|
|
|
|
|
Free text
prsb03-dataelement-13436
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
Name
prsb03-dataelement-11505
|
|
|
| Id |
prsb03-dataelement-11505 (2019‑05‑30 14:35:29)
|
| Concept inherits from |
prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Name in dataset prsb03-dataelement-13313
|
|
|
Role
prsb03-dataelement-11506
|
|
|
| Id |
prsb03-dataelement-11506 (2019‑05‑30 14:35:29)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Role in dataset prsb03-dataelement-13314
|
|
|
Grade
prsb03-dataelement-11507
|
|
|
| Id |
prsb03-dataelement-11507 (2019‑05‑30 14:35:29)
|
| Concept inherits from |
prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Grade in dataset prsb03-dataelement-13315
|
|
|
Speciality
prsb03-dataelement-11508
|
|
|
| Id |
prsb03-dataelement-11508 (2019‑05‑30 14:35:29)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-13316
|
|
|
Professional identifier
prsb03-dataelement-11509
|
|
|
| Id |
prsb03-dataelement-11509 (2019‑05‑30 14:35:29)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Organisation
prsb03-dataelement-11510
|
|
|
| Id |
prsb03-dataelement-11510 (2019‑05‑30 14:35:29)
|
| Concept inherits from |
prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
|
| Description |
The name of the organisation the professional works for. |
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-13318
|
|
|
Contact details
prsb03-dataelement-11511
|
|
|
| Id |
prsb03-dataelement-11511 (2019‑05‑30 14:35:29)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-13319
|
|
|
Person completing record
prsb03-dataelement-11512
|
|
|
|
|
Name
prsb03-dataelement-11513
|
|
|
| Id |
prsb03-dataelement-11513 (2019‑05‑30 14:36:02)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-11514
|
|
|
| Id |
prsb03-dataelement-11514 (2019‑05‑30 14:36:02)
|
| Concept inherits from |
prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-11515
|
|
|
| Id |
prsb03-dataelement-11515 (2019‑05‑30 14:36:02)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-11516
|
|
|
|
|
Organisation
prsb03-dataelement-11517
|
|
|
|
|
Professional identifier
prsb03-dataelement-11518
|
|
|
| Id |
prsb03-dataelement-11518 (2019‑05‑30 14:36:02)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-11519
|
|
|
| Id |
prsb03-dataelement-11519 (2019‑05‑30 14:36:02)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-11520
|
|
|
| Id |
prsb03-dataelement-11520 (2019‑05‑30 14:36:02)
|
| Concept inherits from |
prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
Performing professional
prsb03-dataelement-11260
|
|
|
|
|
Name
prsb03-dataelement-11261
|
|
|
| Id |
prsb03-dataelement-11261 (2019‑05‑29 13:39:03)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-11262
|
|
|
| Id |
prsb03-dataelement-11262 (2019‑05‑29 13:39:03)
|
| Concept inherits from |
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 |
|
|
|
Speciality
prsb03-dataelement-11263
|
|
|
|
|
Team
prsb03-dataelement-11264
|
|
|
|
|
Organisation
prsb03-dataelement-11265
|
|
|
|
|
Contact details
prsb03-dataelement-11266
|
|
|
| Id |
prsb03-dataelement-11266 (2019‑05‑29 13:39:03)
|
| Concept inherits from |
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 |
|
|
|
Professional identifier
prsb03-dataelement-11267
|
|
|
| Id |
prsb03-dataelement-11267 (2019‑05‑29 13:39:03)
|
| Concept inherits from |
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.
|
| FHIR |
PractitionerRole.Practitioner.identifier (local) Practitioner.identifer (professional) |
|
| Value Domain |
|
|
|
Start date
prsb03-dataelement-11268
|
|
|
| Id |
prsb03-dataelement-11268 (2019‑05‑29 13:39:03)
|
| Concept inherits from |
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 |
|
|
|
End date
prsb03-dataelement-11269
|
|
|
| Id |
prsb03-dataelement-11269 (2019‑05‑29 13:39:03)
|
| Concept inherits from |
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 |
|
|
|
Professional contacts record entry
prsb03-dataelement-11270
|
|
|
| Id |
prsb03-dataelement-11270 (2019‑05‑29 13:39:03)
|
| Concept inherits from |
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 |
|
|
|
Person completing record
prsb03-dataelement-11271
|
|
|
|
|
Name
prsb03-dataelement-11272
|
|
|
| Id |
prsb03-dataelement-11272 (2019‑05‑29 13:40:57)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-11273
|
|
|
| Id |
prsb03-dataelement-11273 (2019‑05‑29 13:40:57)
|
| Concept inherits from |
prsb03-dataelement-10220 (2018‑10‑31)
|
| Description |
The role of the person completing record. |
| 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 |
|
|
|
Grade
prsb03-dataelement-11274
|
|
|
| Id |
prsb03-dataelement-11274 (2019‑05‑29 13:40:57)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-11275
|
|
|
| Id |
prsb03-dataelement-11275 (2019‑05‑29 13:40:57)
|
| Concept inherits from |
prsb03-dataelement-10222 (2018‑10‑31)
|
| Description |
The main specialty of the person completing the record. |
| FHIR |
PractitionerRole.specialty |
|
| Operationalization |
The main clinical specialty as held on the source system. |
| Value Domain |
|
|
|
Organisation
prsb03-dataelement-11276
|
|
|
| Id |
prsb03-dataelement-11276 (2019‑05‑29 13:40:57)
|
| Concept inherits from |
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 |
|
|
|
Professional identifier
prsb03-dataelement-11277
|
|
|
| Id |
prsb03-dataelement-11277 (2019‑05‑29 13:40:57)
|
| Concept inherits from |
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.
|
| FHIR |
PractitionerRole.Practitioner.identifier (local) Practitioner.identifer (professional) |
|
| Value Domain |
|
|
|
Date completed
prsb03-dataelement-11278
|
|
|
|
|
Contact details
prsb03-dataelement-11279
|
|
|
| Id |
prsb03-dataelement-11279 (2019‑05‑29 13:40:57)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Performing professional
prsb03-dataelement-11258
|
|
|
|
|
IRRE
prsb03-dataelement-10648
|
|
|
|
|
IRRE
prsb03-dataelement-10647
|
|
|
|
|
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.
|
|
|
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.
|
| 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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 4 times |
| |
|
|
|
Accessible Information
prsb03-dataelement-10064
|
|
|
|
|
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 |
|
|
|
Alerts
prsb03-dataelement-10741
|
|
|
|
|
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
|
|
|
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 |
|
|
|
Location of alert
prsb03-dataelement-10756
|
|
|
|
|
Coded value
prsb03-dataelement-13568
|
|
|
|
|
Free text
prsb03-dataelement-13569
|
|
|
|
|
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 |
|
|
|
Performing professional
prsb03-dataelement-10758
|
|
|
|
|
Name
prsb03-dataelement-12977
|
|
|
| Id |
prsb03-dataelement-12977 (2020‑04‑23 12:56:38)
|
| Concept inherits from |
prsb03-dataelement-12151 (2019‑05‑31 16:09:20)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
|
|
Role
prsb03-dataelement-12978
|
|
|
| Id |
prsb03-dataelement-12978 (2020‑04‑23 12:56:38)
|
| Concept inherits from |
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 |
|
|
|
Grade
prsb03-dataelement-12979
|
|
|
| Id |
prsb03-dataelement-12979 (2020‑04‑23 12:56:38)
|
| Concept inherits from |
prsb03-dataelement-12153 (2019‑05‑31 16:09:20)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Speciality
prsb03-dataelement-12980
|
|
|
|
|
Professional identifier
prsb03-dataelement-12981
|
|
|
| Id |
prsb03-dataelement-12981 (2020‑04‑23 12:56:38)
|
| Concept inherits from |
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 |
|
|
|
Organisation
prsb03-dataelement-12982
|
|
|
|
|
Contact details
prsb03-dataelement-12983
|
|
|
| Id |
prsb03-dataelement-12983 (2020‑04‑23 12:56:38)
|
| Concept inherits from |
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 |
|
|
|
Person completing record
prsb03-dataelement-12399
|
|
|
|
|
Name
prsb03-dataelement-12400
|
|
|
| Id |
prsb03-dataelement-12400 (2019‑06‑05 13:10:34)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-12401
|
|
|
| Id |
prsb03-dataelement-12401 (2019‑06‑05 13:10:34)
|
| Concept inherits from |
prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-12402
|
|
|
| Id |
prsb03-dataelement-12402 (2019‑06‑05 13:10:34)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-12403
|
|
|
|
|
Organisation
prsb03-dataelement-12404
|
|
|
|
|
Professional identifier
prsb03-dataelement-12405
|
|
|
| Id |
prsb03-dataelement-12405 (2019‑06‑05 13:10:34)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-12406
|
|
|
| Id |
prsb03-dataelement-12406 (2019‑06‑05 13:10:34)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-12407
|
|
|
| Id |
prsb03-dataelement-12407 (2019‑06‑05 13:10:34)
|
| Concept inherits from |
prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
Legal information
prsb03-dataelement-520
|
|
|
|
|
Consent for treatment record
prsb03-dataelement-10420
|
|
|
|
|
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 |
|
|
|
Location
prsb03-dataelement-13459
|
|
|
|
|
Coded value
prsb03-dataelement-13460
|
|
|
|
|
Free text
prsb03-dataelement-13461
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Name
prsb03-dataelement-13463
|
|
|
| Id |
prsb03-dataelement-13463 (2020‑09‑02 12:38:25)
|
| Concept inherits from |
prsb03-dataelement-11735 (2019‑05‑31 13:23:55)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
This concept is inherited by concept
Name in dataset prsb03-dataelement-13639
This concept is inherited by concept
Name in dataset prsb03-dataelement-13485
|
|
|
Role
prsb03-dataelement-13464
|
|
|
| Id |
prsb03-dataelement-13464 (2020‑09‑02 12:38:25)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
This concept is inherited by concept
Role in dataset prsb03-dataelement-13640
This concept is inherited by concept
Role in dataset prsb03-dataelement-13486
|
|
|
Grade
prsb03-dataelement-13465
|
|
|
| Id |
prsb03-dataelement-13465 (2020‑09‑02 12:38:25)
|
| Concept inherits from |
prsb03-dataelement-11737 (2019‑05‑31 13:23:55)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
This concept is inherited by concept
Grade in dataset prsb03-dataelement-13641
This concept is inherited by concept
Grade in dataset prsb03-dataelement-13487
|
|
|
Speciality
prsb03-dataelement-13466
|
|
|
| Id |
prsb03-dataelement-13466 (2020‑09‑02 12:38:25)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-13642
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-13488
|
|
|
Professional identifier
prsb03-dataelement-13467
|
|
|
| Id |
prsb03-dataelement-13467 (2020‑09‑02 12:38:25)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
|
|
|
Organisation
prsb03-dataelement-13468
|
|
|
| Id |
prsb03-dataelement-13468 (2020‑09‑02 12:38:25)
|
| Concept inherits from |
prsb03-dataelement-11740 (2019‑05‑31 13:23:55)
|
| Description |
The name of the organisation the professional works for. |
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-13644
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-13490
|
|
|
Contact details
prsb03-dataelement-13469
|
|
|
| Id |
prsb03-dataelement-13469 (2020‑09‑02 12:38:25)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-13645
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-13491
|
|
|
Person completing record
prsb03-dataelement-13470
|
|
|
|
|
Name
prsb03-dataelement-13471
|
|
|
| Id |
prsb03-dataelement-13471 (2020‑09‑02 12:41:04)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-13472
|
|
|
| Id |
prsb03-dataelement-13472 (2020‑09‑02 12:41:04)
|
| Concept inherits from |
prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-13473
|
|
|
| Id |
prsb03-dataelement-13473 (2020‑09‑02 12:41:04)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-13474
|
|
|
|
|
Organisation
prsb03-dataelement-13475
|
|
|
|
|
Professional identifier
prsb03-dataelement-13476
|
|
|
| Id |
prsb03-dataelement-13476 (2020‑09‑02 12:41:04)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-13477
|
|
|
| Id |
prsb03-dataelement-13477 (2020‑09‑02 12:41:04)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-13478
|
|
|
| Id |
prsb03-dataelement-13478 (2020‑09‑02 12:41:04)
|
| Concept inherits from |
prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
Location
prsb03-dataelement-13458
|
|
|
|
|
Consent for information sharing
prsb03-dataelement-10421
|
|
|
|
|
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 |
|
|
|
Location
prsb03-dataelement-11714
|
|
|
|
|
Coded value
prsb03-dataelement-13451
|
|
|
|
|
Free text
prsb03-dataelement-13452
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Name
prsb03-dataelement-11716
|
|
|
| Id |
prsb03-dataelement-11716 (2019‑05‑31 13:17:18)
|
| Concept inherits from |
prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
|
|
Role
prsb03-dataelement-11717
|
|
|
| Id |
prsb03-dataelement-11717 (2019‑05‑31 13:17:18)
|
| Concept inherits from |
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 |
|
|
|
Grade
prsb03-dataelement-11718
|
|
|
| Id |
prsb03-dataelement-11718 (2019‑05‑31 13:17:18)
|
| Concept inherits from |
prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Speciality
prsb03-dataelement-11719
|
|
|
|
|
Professional identifier
prsb03-dataelement-11720
|
|
|
| Id |
prsb03-dataelement-11720 (2019‑05‑31 13:17:18)
|
| Concept inherits from |
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 |
|
|
|
Organisation
prsb03-dataelement-11721
|
|
|
|
|
Contact details
prsb03-dataelement-11722
|
|
|
| Id |
prsb03-dataelement-11722 (2019‑05‑31 13:17:18)
|
| Concept inherits from |
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 |
|
|
|
Person completing record
prsb03-dataelement-11723
|
|
|
|
|
Name
prsb03-dataelement-11724
|
|
|
| Id |
prsb03-dataelement-11724 (2019‑05‑31 13:17:58)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-11725
|
|
|
| Id |
prsb03-dataelement-11725 (2019‑05‑31 13:17:58)
|
| Concept inherits from |
prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-11726
|
|
|
| Id |
prsb03-dataelement-11726 (2019‑05‑31 13:17:58)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-11727
|
|
|
|
|
Organisation
prsb03-dataelement-11728
|
|
|
|
|
Professional identifier
prsb03-dataelement-11729
|
|
|
| Id |
prsb03-dataelement-11729 (2019‑05‑31 13:17:58)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-11730
|
|
|
| Id |
prsb03-dataelement-11730 (2019‑05‑31 13:17:58)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-11731
|
|
|
| Id |
prsb03-dataelement-11731 (2019‑05‑31 13:17:58)
|
| Concept inherits from |
prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
Consent relating to child
prsb03-dataelement-10422
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
Coded value
prsb03-dataelement-13674
|
|
|
|
|
Free text
prsb03-dataelement-13675
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
Name
prsb03-dataelement-11735
|
|
|
| Id |
prsb03-dataelement-11735 (2019‑05‑31 13:23:55)
|
| Concept inherits from |
prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Name in dataset prsb03-dataelement-13463
|
|
|
Role
prsb03-dataelement-11736
|
|
|
| Id |
prsb03-dataelement-11736 (2019‑05‑31 13:23:55)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Role in dataset prsb03-dataelement-13464
|
|
|
Grade
prsb03-dataelement-11737
|
|
|
| Id |
prsb03-dataelement-11737 (2019‑05‑31 13:23:55)
|
| Concept inherits from |
prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Grade in dataset prsb03-dataelement-13465
|
|
|
Speciality
prsb03-dataelement-11738
|
|
|
| Id |
prsb03-dataelement-11738 (2019‑05‑31 13:23:55)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-13466
|
|
|
Professional identifier
prsb03-dataelement-11739
|
|
|
| Id |
prsb03-dataelement-11739 (2019‑05‑31 13:23:55)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Organisation
prsb03-dataelement-11740
|
|
|
| Id |
prsb03-dataelement-11740 (2019‑05‑31 13:23:55)
|
| Concept inherits from |
prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
|
| Description |
The name of the organisation the professional works for. |
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-13468
|
|
|
Contact details
prsb03-dataelement-11741
|
|
|
| Id |
prsb03-dataelement-11741 (2019‑05‑31 13:23:55)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-13469
|
|
|
Person completing record
prsb03-dataelement-11742
|
|
|
|
|
Name
prsb03-dataelement-11743
|
|
|
| Id |
prsb03-dataelement-11743 (2019‑05‑31 13:24:18)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-11744
|
|
|
| Id |
prsb03-dataelement-11744 (2019‑05‑31 13:24:18)
|
| Concept inherits from |
prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-11745
|
|
|
| Id |
prsb03-dataelement-11745 (2019‑05‑31 13:24:18)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-11746
|
|
|
|
|
Organisation
prsb03-dataelement-11747
|
|
|
|
|
Professional identifier
prsb03-dataelement-11748
|
|
|
| Id |
prsb03-dataelement-11748 (2019‑05‑31 13:24:18)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-11749
|
|
|
| Id |
prsb03-dataelement-11749 (2019‑05‑31 13:24:18)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-11750
|
|
|
| Id |
prsb03-dataelement-11750 (2019‑05‑31 13:24:18)
|
| Concept inherits from |
prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
Mental capacity assessment
prsb03-dataelement-10424
|
|
|
| Id |
prsb03-dataelement-10424 (2018‑10‑31)
|
| Description |
Details of the persons mental capacity assessment |
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 3 times |
| |
This concept is inherited by concept
Date in dataset prsb03-dataelement-11695
This concept is inherited by concept
Date in dataset prsb03-dataelement-11693
This concept is inherited by concept
Date in dataset prsb03-dataelement-12343
|
|
|
Location
prsb03-dataelement-11689
|
|
|
| Id |
prsb03-dataelement-11689 (2019‑05‑31 11:51:04)
|
| Description |
The location where the mental capacity assessment was made. |
Used by
|
0 transactions, 0 templates, inherited 3 times |
| |
This concept is inherited by concept
Location in dataset prsb03-dataelement-11696
This concept is inherited by concept
Location in dataset prsb03-dataelement-11694
This concept is inherited by concept
Location in dataset prsb03-dataelement-12344
|
|
|
Coded value
prsb03-dataelement-13449
|
|
|
| Id |
prsb03-dataelement-13449 (2020‑08‑27 16:43:20)
|
| Description |
The coded value for location |
| Operationalization |
|
| Value Domain |
|
| Property |
| min length |
max length |
| 3 |
5 |
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 3 times |
| |
This concept is inherited by concept
Free text in dataset prsb03-dataelement-13788
This concept is inherited by concept
Free text in dataset prsb03-dataelement-13781
This concept is inherited by concept
Free text in dataset prsb03-dataelement-13750
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Performing professional
prsb03-dataelement-11281
|
|
|
| Id |
prsb03-dataelement-11281 (2019‑05‑30 11:53:30)
|
| Description |
The professional who made the mental capacity assessment. |
Used by
|
0 transactions, 0 templates, inherited 3 times |
| |
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 61 times |
| |
This concept is inherited by concept
Name in dataset prsb03-dataelement-11403
This concept is inherited by concept
Name in dataset prsb03-dataelement-11420
This concept is inherited by concept
Name in dataset prsb03-dataelement-11437
This concept is inherited by concept
Name in dataset prsb03-dataelement-11454
This concept is inherited by concept
Name in dataset prsb03-dataelement-11471
This concept is inherited by concept
Name in dataset prsb03-dataelement-11488
This concept is inherited by concept
Name in dataset prsb03-dataelement-11505
This concept is inherited by concept
Name in dataset prsb03-dataelement-11716
This concept is inherited by concept
Name in dataset prsb03-dataelement-11735
This concept is inherited by concept
Name in dataset prsb03-dataelement-13074
This concept is inherited by concept
Name in dataset prsb03-dataelement-11299
This concept is inherited by concept
Name in dataset prsb03-dataelement-11316
This concept is inherited by concept
Name in dataset prsb03-dataelement-11333
This concept is inherited by concept
Name in dataset prsb03-dataelement-11359
This concept is inherited by concept
Name in dataset prsb03-dataelement-12185
This concept is inherited by concept
Name in dataset prsb03-dataelement-12134
This concept is inherited by concept
Name in dataset prsb03-dataelement-12151
This concept is inherited by concept
Name in dataset prsb03-dataelement-11649
This concept is inherited by concept
Name in dataset prsb03-dataelement-11657
This concept is inherited by concept
Name in dataset prsb03-dataelement-11777
This concept is inherited by concept
Name in dataset prsb03-dataelement-11787
This concept is inherited by concept
Name in dataset prsb03-dataelement-11797
This concept is inherited by concept
Name in dataset prsb03-dataelement-11807
This concept is inherited by concept
Name in dataset prsb03-dataelement-11817
This concept is inherited by concept
Name in dataset prsb03-dataelement-11827
This concept is inherited by concept
Name in dataset prsb03-dataelement-11847
This concept is inherited by concept
Name in dataset prsb03-dataelement-11857
This concept is inherited by concept
Name in dataset prsb03-dataelement-11867
This concept is inherited by concept
Name in dataset prsb03-dataelement-11886
This concept is inherited by concept
Name in dataset prsb03-dataelement-11837
This concept is inherited by concept
Name in dataset prsb03-dataelement-11641
This concept is inherited by concept
Name in dataset prsb03-dataelement-12100
This concept is inherited by concept
Name in dataset prsb03-dataelement-12082
This concept is inherited by concept
Name in dataset prsb03-dataelement-12117
This concept is inherited by concept
Name in dataset prsb03-dataelement-13534
This concept is inherited by concept
Name in dataset prsb03-dataelement-12391
This concept is inherited by concept
Name in dataset prsb03-dataelement-12383
This concept is inherited by concept
Name in dataset prsb03-dataelement-11672
This concept is inherited by concept
Name in dataset prsb03-dataelement-11897
This concept is inherited by concept
Name in dataset prsb03-dataelement-11917
This concept is inherited by concept
Name in dataset prsb03-dataelement-11937
This concept is inherited by concept
Name in dataset prsb03-dataelement-11957
This concept is inherited by concept
Name in dataset prsb03-dataelement-11977
This concept is inherited by concept
Name in dataset prsb03-dataelement-12011
This concept is inherited by concept
Name in dataset prsb03-dataelement-12003
This concept is inherited by concept
Name in dataset prsb03-dataelement-12168
This concept is inherited by concept
Name in dataset prsb03-dataelement-12028
This concept is inherited by concept
Name in dataset prsb03-dataelement-12270
This concept is inherited by concept
Name in dataset prsb03-dataelement-12046
This concept is inherited by concept
Name in dataset prsb03-dataelement-12063
This concept is inherited by concept
Name in dataset prsb03-dataelement-12213
This concept is inherited by concept
Name in dataset prsb03-dataelement-12232
This concept is inherited by concept
Name in dataset prsb03-dataelement-12251
This concept is inherited by concept
Name in dataset prsb03-dataelement-12289
This concept is inherited by concept
Name in dataset prsb03-dataelement-12308
This concept is inherited by concept
Name in dataset prsb03-dataelement-12327
This concept is inherited by concept
Name in dataset prsb03-dataelement-12346
This concept is inherited by concept
Name in dataset prsb03-dataelement-12365
This concept is inherited by concept
Name in dataset prsb03-dataelement-12423
This concept is inherited by concept
Name in dataset prsb03-dataelement-12453
This concept is inherited by concept
Name in dataset prsb03-dataelement-12440
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 60 times |
| |
This concept is inherited by concept
Role in dataset prsb03-dataelement-11404
This concept is inherited by concept
Role in dataset prsb03-dataelement-11421
This concept is inherited by concept
Role in dataset prsb03-dataelement-11438
This concept is inherited by concept
Role in dataset prsb03-dataelement-11455
This concept is inherited by concept
Role in dataset prsb03-dataelement-11472
This concept is inherited by concept
Role in dataset prsb03-dataelement-11489
This concept is inherited by concept
Role in dataset prsb03-dataelement-11506
This concept is inherited by concept
Role in dataset prsb03-dataelement-11717
This concept is inherited by concept
Role in dataset prsb03-dataelement-11736
This concept is inherited by concept
Role in dataset prsb03-dataelement-13075
This concept is inherited by concept
Role in dataset prsb03-dataelement-11300
This concept is inherited by concept
Role in dataset prsb03-dataelement-11317
This concept is inherited by concept
Role in dataset prsb03-dataelement-11334
This concept is inherited by concept
Role in dataset prsb03-dataelement-11360
This concept is inherited by concept
Role in dataset prsb03-dataelement-12135
This concept is inherited by concept
Role in dataset prsb03-dataelement-12152
This concept is inherited by concept
Role in dataset prsb03-dataelement-11650
This concept is inherited by concept
Role in dataset prsb03-dataelement-11658
This concept is inherited by concept
Role in dataset prsb03-dataelement-11778
This concept is inherited by concept
Role in dataset prsb03-dataelement-11788
This concept is inherited by concept
Role in dataset prsb03-dataelement-11798
This concept is inherited by concept
Role in dataset prsb03-dataelement-11808
This concept is inherited by concept
Role in dataset prsb03-dataelement-11818
This concept is inherited by concept
Role in dataset prsb03-dataelement-11828
This concept is inherited by concept
Role in dataset prsb03-dataelement-11848
This concept is inherited by concept
Role in dataset prsb03-dataelement-11858
This concept is inherited by concept
Role in dataset prsb03-dataelement-11868
This concept is inherited by concept
Role in dataset prsb03-dataelement-11887
This concept is inherited by concept
Role in dataset prsb03-dataelement-11838
This concept is inherited by concept
Role in dataset prsb03-dataelement-11642
This concept is inherited by concept
Role in dataset prsb03-dataelement-12101
This concept is inherited by concept
Role in dataset prsb03-dataelement-12083
This concept is inherited by concept
Role in dataset prsb03-dataelement-12118
This concept is inherited by concept
Role in dataset prsb03-dataelement-13535
This concept is inherited by concept
Role in dataset prsb03-dataelement-12392
This concept is inherited by concept
Role in dataset prsb03-dataelement-12384
This concept is inherited by concept
Role in dataset prsb03-dataelement-11673
This concept is inherited by concept
Role in dataset prsb03-dataelement-11898
This concept is inherited by concept
Role in dataset prsb03-dataelement-11918
This concept is inherited by concept
Role in dataset prsb03-dataelement-11938
This concept is inherited by concept
Role in dataset prsb03-dataelement-11958
This concept is inherited by concept
Role in dataset prsb03-dataelement-11978
This concept is inherited by concept
Role in dataset prsb03-dataelement-12012
This concept is inherited by concept
Role in dataset prsb03-dataelement-12004
This concept is inherited by concept
Role in dataset prsb03-dataelement-12169
This concept is inherited by concept
Role in dataset prsb03-dataelement-12029
This concept is inherited by concept
Role in dataset prsb03-dataelement-12271
This concept is inherited by concept
Role in dataset prsb03-dataelement-12047
This concept is inherited by concept
Role in dataset prsb03-dataelement-12064
This concept is inherited by concept
Role in dataset prsb03-dataelement-12214
This concept is inherited by concept
Role in dataset prsb03-dataelement-12233
This concept is inherited by concept
Role in dataset prsb03-dataelement-12252
This concept is inherited by concept
Role in dataset prsb03-dataelement-12290
This concept is inherited by concept
Role in dataset prsb03-dataelement-12309
This concept is inherited by concept
Role in dataset prsb03-dataelement-12328
This concept is inherited by concept
Role in dataset prsb03-dataelement-12347
This concept is inherited by concept
Role in dataset prsb03-dataelement-12366
This concept is inherited by concept
Role in dataset prsb03-dataelement-12424
This concept is inherited by concept
Role in dataset prsb03-dataelement-12454
This concept is inherited by concept
Role in dataset prsb03-dataelement-12441
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 61 times |
| |
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11405
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11422
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11439
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11456
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11473
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11490
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11507
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11718
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11737
This concept is inherited by concept
Grade in dataset prsb03-dataelement-13076
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11301
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11318
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11335
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11361
This concept is inherited by concept
Grade in dataset prsb03-dataelement-12187
This concept is inherited by concept
Grade in dataset prsb03-dataelement-12136
This concept is inherited by concept
Grade in dataset prsb03-dataelement-12153
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11651
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11659
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11779
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11789
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11799
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11809
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11819
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11829
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11849
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11859
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11869
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11888
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11839
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11643
This concept is inherited by concept
Grade in dataset prsb03-dataelement-12102
This concept is inherited by concept
Grade in dataset prsb03-dataelement-12084
This concept is inherited by concept
Grade in dataset prsb03-dataelement-12119
This concept is inherited by concept
Grade in dataset prsb03-dataelement-13536
This concept is inherited by concept
Grade in dataset prsb03-dataelement-12393
This concept is inherited by concept
Grade in dataset prsb03-dataelement-12385
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11674
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11899
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11919
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11939
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11959
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11979
This concept is inherited by concept
Grade in dataset prsb03-dataelement-12013
This concept is inherited by concept
Grade in dataset prsb03-dataelement-12005
This concept is inherited by concept
Grade in dataset prsb03-dataelement-12170
This concept is inherited by concept
Grade in dataset prsb03-dataelement-12030
This concept is inherited by concept
Grade in dataset prsb03-dataelement-12272
This concept is inherited by concept
Grade in dataset prsb03-dataelement-12048
This concept is inherited by concept
Grade in dataset prsb03-dataelement-12065
This concept is inherited by concept
Grade in dataset prsb03-dataelement-12215
This concept is inherited by concept
Grade in dataset prsb03-dataelement-12234
This concept is inherited by concept
Grade in dataset prsb03-dataelement-12253
This concept is inherited by concept
Grade in dataset prsb03-dataelement-12291
This concept is inherited by concept
Grade in dataset prsb03-dataelement-12310
This concept is inherited by concept
Grade in dataset prsb03-dataelement-12329
This concept is inherited by concept
Grade in dataset prsb03-dataelement-12348
This concept is inherited by concept
Grade in dataset prsb03-dataelement-12367
This concept is inherited by concept
Grade in dataset prsb03-dataelement-12425
This concept is inherited by concept
Grade in dataset prsb03-dataelement-12455
This concept is inherited by concept
Grade in dataset prsb03-dataelement-12442
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 60 times |
| |
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-11406
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-11423
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-11440
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-11457
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-11474
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-11491
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-11508
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-11719
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-11738
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-13077
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-11302
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-11319
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-11336
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-11362
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-12137
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-12154
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-11652
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-11660
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-11780
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-11790
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-11800
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-11810
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-11820
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-11830
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-11850
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-11860
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-11870
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-11889
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-11840
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-11644
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-12103
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-12085
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-12120
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-13537
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-12394
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-12386
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-11675
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-11900
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-11920
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-11940
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-11960
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-11980
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-12014
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-12006
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-12171
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-12031
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-12273
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-12049
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-12066
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-12216
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-12235
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-12254
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-12292
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-12311
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-12330
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-12349
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-12368
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-12426
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-12456
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-12443
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 61 times |
| |
|
|
|
Organisation
prsb03-dataelement-11286
|
|
|
| Id |
prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
|
| Description |
The name of the organisation the professional works for. |
Used by
|
0 transactions, 0 templates, inherited 61 times |
| |
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11408
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11425
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11442
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11459
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11476
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11493
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11510
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11721
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11740
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-13079
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11304
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11321
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11338
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11364
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-12190
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-12139
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-12156
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11654
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11662
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11782
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11792
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11802
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11812
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11822
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11832
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11852
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11862
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11872
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11891
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11842
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11646
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-12105
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-12087
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-12122
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-13539
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-12396
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-12388
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11677
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11902
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11922
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11942
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11962
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11982
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-12016
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-12008
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-12173
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-12033
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-12275
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-12051
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-12068
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-12218
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-12237
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-12256
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-12294
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-12313
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-12332
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-12351
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-12370
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-12428
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-12458
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-12445
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Coded value in dataset prsb03-dataelement-13540
|
|
|
Free text
prsb03-dataelement-13522
|
|
|
| Id |
prsb03-dataelement-13522 (2020‑09‑04 13:45:47)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Free text in dataset prsb03-dataelement-13541
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 61 times |
| |
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11409
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11426
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11443
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11460
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11477
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11494
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11511
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11722
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11741
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-13080
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11305
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11322
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11339
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11365
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-12191
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-12140
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-12157
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11655
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11663
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11783
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11793
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11803
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11813
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11823
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11833
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11853
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11863
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11873
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11892
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11843
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11647
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-12106
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-12088
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-12123
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-13542
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-12397
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-12389
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11678
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11903
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11923
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11943
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11963
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11983
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-12017
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-12009
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-12174
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-12034
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-12276
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-12052
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-12069
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-12219
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-12238
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-12257
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-12295
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-12314
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-12333
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-12352
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-12371
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-12429
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-12459
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-12446
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 67 times |
| |
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 69 times |
| |
This concept is inherited by concept
Name in dataset prsb03-dataelement-11350
This concept is inherited by concept
Name in dataset prsb03-dataelement-11411
This concept is inherited by concept
Name in dataset prsb03-dataelement-11428
This concept is inherited by concept
Name in dataset prsb03-dataelement-11445
This concept is inherited by concept
Name in dataset prsb03-dataelement-11462
This concept is inherited by concept
Name in dataset prsb03-dataelement-13036
This concept is inherited by concept
Name in dataset prsb03-dataelement-13053
This concept is inherited by concept
Name in dataset prsb03-dataelement-11479
This concept is inherited by concept
Name in dataset prsb03-dataelement-11496
This concept is inherited by concept
Name in dataset prsb03-dataelement-11513
This concept is inherited by concept
Name in dataset prsb03-dataelement-12400
This concept is inherited by concept
Name in dataset prsb03-dataelement-13471
This concept is inherited by concept
Name in dataset prsb03-dataelement-11724
This concept is inherited by concept
Name in dataset prsb03-dataelement-11743
This concept is inherited by concept
Name in dataset prsb03-dataelement-11307
This concept is inherited by concept
Name in dataset prsb03-dataelement-11324
This concept is inherited by concept
Name in dataset prsb03-dataelement-11341
This concept is inherited by concept
Name in dataset prsb03-dataelement-11367
This concept is inherited by concept
Name in dataset prsb03-dataelement-11376
This concept is inherited by concept
Name in dataset prsb03-dataelement-11385
This concept is inherited by concept
Name in dataset prsb03-dataelement-11394
This concept is inherited by concept
Name in dataset prsb03-dataelement-12202
This concept is inherited by concept
Name in dataset prsb03-dataelement-12193
This concept is inherited by concept
Name in dataset prsb03-dataelement-12142
This concept is inherited by concept
Name in dataset prsb03-dataelement-12159
This concept is inherited by concept
Name in dataset prsb03-dataelement-11522
This concept is inherited by concept
Name in dataset prsb03-dataelement-11531
This concept is inherited by concept
Name in dataset prsb03-dataelement-11540
This concept is inherited by concept
Name in dataset prsb03-dataelement-11549
This concept is inherited by concept
Name in dataset prsb03-dataelement-11558
This concept is inherited by concept
Name in dataset prsb03-dataelement-11567
This concept is inherited by concept
Name in dataset prsb03-dataelement-11576
This concept is inherited by concept
Name in dataset prsb03-dataelement-11585
This concept is inherited by concept
Name in dataset prsb03-dataelement-11603
This concept is inherited by concept
Name in dataset prsb03-dataelement-11612
This concept is inherited by concept
Name in dataset prsb03-dataelement-11875
This concept is inherited by concept
Name in dataset prsb03-dataelement-11622
This concept is inherited by concept
Name in dataset prsb03-dataelement-11594
This concept is inherited by concept
Name in dataset prsb03-dataelement-11631
This concept is inherited by concept
Name in dataset prsb03-dataelement-12108
This concept is inherited by concept
Name in dataset prsb03-dataelement-12091
This concept is inherited by concept
Name in dataset prsb03-dataelement-12125
This concept is inherited by concept
Name in dataset prsb03-dataelement-13544
This concept is inherited by concept
Name in dataset prsb03-dataelement-11762
This concept is inherited by concept
Name in dataset prsb03-dataelement-11753
This concept is inherited by concept
Name in dataset prsb03-dataelement-11680
This concept is inherited by concept
Name in dataset prsb03-dataelement-11905
This concept is inherited by concept
Name in dataset prsb03-dataelement-11925
This concept is inherited by concept
Name in dataset prsb03-dataelement-11945
This concept is inherited by concept
Name in dataset prsb03-dataelement-11965
This concept is inherited by concept
Name in dataset prsb03-dataelement-11985
This concept is inherited by concept
Name in dataset prsb03-dataelement-12019
This concept is inherited by concept
Name in dataset prsb03-dataelement-11994
This concept is inherited by concept
Name in dataset prsb03-dataelement-12176
This concept is inherited by concept
Name in dataset prsb03-dataelement-12606
This concept is inherited by concept
Name in dataset prsb03-dataelement-12036
This concept is inherited by concept
Name in dataset prsb03-dataelement-12278
This concept is inherited by concept
Name in dataset prsb03-dataelement-12054
This concept is inherited by concept
Name in dataset prsb03-dataelement-12071
This concept is inherited by concept
Name in dataset prsb03-dataelement-12221
This concept is inherited by concept
Name in dataset prsb03-dataelement-12240
This concept is inherited by concept
Name in dataset prsb03-dataelement-12259
This concept is inherited by concept
Name in dataset prsb03-dataelement-12297
This concept is inherited by concept
Name in dataset prsb03-dataelement-12316
This concept is inherited by concept
Name in dataset prsb03-dataelement-12335
This concept is inherited by concept
Name in dataset prsb03-dataelement-12354
This concept is inherited by concept
Name in dataset prsb03-dataelement-12373
This concept is inherited by concept
Name in dataset prsb03-dataelement-12431
This concept is inherited by concept
Name in dataset prsb03-dataelement-12463
|
|
|
Role
prsb03-dataelement-11291
|
|
|
| Id |
prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
Used by
|
0 transactions, 0 templates, inherited 69 times |
| |
This concept is inherited by concept
Role in dataset prsb03-dataelement-11351
This concept is inherited by concept
Role in dataset prsb03-dataelement-11412
This concept is inherited by concept
Role in dataset prsb03-dataelement-11429
This concept is inherited by concept
Role in dataset prsb03-dataelement-11446
This concept is inherited by concept
Role in dataset prsb03-dataelement-11463
This concept is inherited by concept
Role in dataset prsb03-dataelement-13037
This concept is inherited by concept
Role in dataset prsb03-dataelement-13054
This concept is inherited by concept
Role in dataset prsb03-dataelement-11480
This concept is inherited by concept
Role in dataset prsb03-dataelement-11497
This concept is inherited by concept
Role in dataset prsb03-dataelement-11514
This concept is inherited by concept
Role in dataset prsb03-dataelement-12401
This concept is inherited by concept
Role in dataset prsb03-dataelement-13472
This concept is inherited by concept
Role in dataset prsb03-dataelement-11725
This concept is inherited by concept
Role in dataset prsb03-dataelement-11744
This concept is inherited by concept
Role in dataset prsb03-dataelement-11308
This concept is inherited by concept
Role in dataset prsb03-dataelement-11325
This concept is inherited by concept
Role in dataset prsb03-dataelement-11342
This concept is inherited by concept
Role in dataset prsb03-dataelement-11368
This concept is inherited by concept
Role in dataset prsb03-dataelement-11377
This concept is inherited by concept
Role in dataset prsb03-dataelement-11386
This concept is inherited by concept
Role in dataset prsb03-dataelement-11395
This concept is inherited by concept
Role in dataset prsb03-dataelement-12203
This concept is inherited by concept
Role in dataset prsb03-dataelement-12194
This concept is inherited by concept
Role in dataset prsb03-dataelement-12143
This concept is inherited by concept
Role in dataset prsb03-dataelement-12160
This concept is inherited by concept
Role in dataset prsb03-dataelement-11523
This concept is inherited by concept
Role in dataset prsb03-dataelement-11532
This concept is inherited by concept
Role in dataset prsb03-dataelement-11541
This concept is inherited by concept
Role in dataset prsb03-dataelement-11550
This concept is inherited by concept
Role in dataset prsb03-dataelement-11559
This concept is inherited by concept
Role in dataset prsb03-dataelement-11568
This concept is inherited by concept
Role in dataset prsb03-dataelement-11577
This concept is inherited by concept
Role in dataset prsb03-dataelement-11586
This concept is inherited by concept
Role in dataset prsb03-dataelement-11604
This concept is inherited by concept
Role in dataset prsb03-dataelement-11613
This concept is inherited by concept
Role in dataset prsb03-dataelement-11876
This concept is inherited by concept
Role in dataset prsb03-dataelement-11623
This concept is inherited by concept
Role in dataset prsb03-dataelement-11595
This concept is inherited by concept
Role in dataset prsb03-dataelement-11632
This concept is inherited by concept
Role in dataset prsb03-dataelement-12109
This concept is inherited by concept
Role in dataset prsb03-dataelement-12092
This concept is inherited by concept
Role in dataset prsb03-dataelement-12126
This concept is inherited by concept
Role in dataset prsb03-dataelement-13545
This concept is inherited by concept
Role in dataset prsb03-dataelement-11763
This concept is inherited by concept
Role in dataset prsb03-dataelement-11754
This concept is inherited by concept
Role in dataset prsb03-dataelement-11681
This concept is inherited by concept
Role in dataset prsb03-dataelement-11906
This concept is inherited by concept
Role in dataset prsb03-dataelement-11926
This concept is inherited by concept
Role in dataset prsb03-dataelement-11946
This concept is inherited by concept
Role in dataset prsb03-dataelement-11966
This concept is inherited by concept
Role in dataset prsb03-dataelement-11986
This concept is inherited by concept
Role in dataset prsb03-dataelement-12020
This concept is inherited by concept
Role in dataset prsb03-dataelement-11995
This concept is inherited by concept
Role in dataset prsb03-dataelement-12177
This concept is inherited by concept
Role in dataset prsb03-dataelement-12607
This concept is inherited by concept
Role in dataset prsb03-dataelement-12037
This concept is inherited by concept
Role in dataset prsb03-dataelement-12279
This concept is inherited by concept
Role in dataset prsb03-dataelement-12055
This concept is inherited by concept
Role in dataset prsb03-dataelement-12072
This concept is inherited by concept
Role in dataset prsb03-dataelement-12222
This concept is inherited by concept
Role in dataset prsb03-dataelement-12241
This concept is inherited by concept
Role in dataset prsb03-dataelement-12260
This concept is inherited by concept
Role in dataset prsb03-dataelement-12298
This concept is inherited by concept
Role in dataset prsb03-dataelement-12317
This concept is inherited by concept
Role in dataset prsb03-dataelement-12336
This concept is inherited by concept
Role in dataset prsb03-dataelement-12355
This concept is inherited by concept
Role in dataset prsb03-dataelement-12374
This concept is inherited by concept
Role in dataset prsb03-dataelement-12432
This concept is inherited by concept
Role in dataset prsb03-dataelement-12464
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 69 times |
| |
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11352
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11413
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11430
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11447
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11464
This concept is inherited by concept
Grade in dataset prsb03-dataelement-13038
This concept is inherited by concept
Grade in dataset prsb03-dataelement-13055
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11481
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11498
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11515
This concept is inherited by concept
Grade in dataset prsb03-dataelement-12402
This concept is inherited by concept
Grade in dataset prsb03-dataelement-13473
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11726
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11745
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11309
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11326
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11343
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11369
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11378
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11387
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11396
This concept is inherited by concept
Grade in dataset prsb03-dataelement-12204
This concept is inherited by concept
Grade in dataset prsb03-dataelement-12195
This concept is inherited by concept
Grade in dataset prsb03-dataelement-12144
This concept is inherited by concept
Grade in dataset prsb03-dataelement-12161
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11524
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11533
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11542
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11551
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11560
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11569
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11578
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11587
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11605
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11614
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11877
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11624
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11596
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11633
This concept is inherited by concept
Grade in dataset prsb03-dataelement-12110
This concept is inherited by concept
Grade in dataset prsb03-dataelement-12093
This concept is inherited by concept
Grade in dataset prsb03-dataelement-12127
This concept is inherited by concept
Grade in dataset prsb03-dataelement-13546
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11764
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11755
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11682
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11907
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11927
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11947
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11967
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11987
This concept is inherited by concept
Grade in dataset prsb03-dataelement-12021
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11996
This concept is inherited by concept
Grade in dataset prsb03-dataelement-12178
This concept is inherited by concept
Grade in dataset prsb03-dataelement-12608
This concept is inherited by concept
Grade in dataset prsb03-dataelement-12038
This concept is inherited by concept
Grade in dataset prsb03-dataelement-12280
This concept is inherited by concept
Grade in dataset prsb03-dataelement-12056
This concept is inherited by concept
Grade in dataset prsb03-dataelement-12073
This concept is inherited by concept
Grade in dataset prsb03-dataelement-12223
This concept is inherited by concept
Grade in dataset prsb03-dataelement-12242
This concept is inherited by concept
Grade in dataset prsb03-dataelement-12261
This concept is inherited by concept
Grade in dataset prsb03-dataelement-12299
This concept is inherited by concept
Grade in dataset prsb03-dataelement-12318
This concept is inherited by concept
Grade in dataset prsb03-dataelement-12337
This concept is inherited by concept
Grade in dataset prsb03-dataelement-12356
This concept is inherited by concept
Grade in dataset prsb03-dataelement-12375
This concept is inherited by concept
Grade in dataset prsb03-dataelement-12433
This concept is inherited by concept
Grade in dataset prsb03-dataelement-12465
|
|
|
Specialty
prsb03-dataelement-11293
|
|
|
| Id |
prsb03-dataelement-11293 (2019‑05‑30 12:25:39)
|
| Description |
The main specialty of the person completing the record. |
| FHIR |
PractitionerRole.specialty |
|
| Relationship |
|
| Rationale |
PractitionerRole.speciality |
| Operationalization |
NHS data dictionary :-
Activity treatment function code
|
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited 69 times |
| |
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-11353
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-11414
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-11431
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-11448
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-11465
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-13039
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-13056
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-11482
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-11499
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-11516
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-12403
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-13474
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-11727
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-11746
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-11310
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-11327
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-11344
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-11370
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-11379
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-11388
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-11397
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-12205
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-12196
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-12145
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-12162
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-11525
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-11534
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-11543
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-11552
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-11561
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-11570
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-11579
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-11588
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-11606
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-11615
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-11878
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-11625
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-11597
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-11634
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-12111
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-12094
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-12128
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-13547
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-11765
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-11756
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-11683
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-11908
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-11928
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-11948
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-11968
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-11988
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-12022
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-11997
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-12179
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-12609
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-12039
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-12281
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-12057
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-12074
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-12224
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-12243
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-12262
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-12300
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-12319
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-12338
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-12357
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-12376
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-12434
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-12466
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 69 times |
| |
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11354
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11415
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11432
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11449
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11466
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-13040
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-13057
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11483
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11500
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11517
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-12404
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-13475
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11728
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11747
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11311
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11328
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11345
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11371
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11380
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11389
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11398
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-12206
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-12197
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-12146
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-12163
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11526
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11535
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11544
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11553
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11562
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11571
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11580
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11589
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11607
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11616
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11879
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11626
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11598
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11635
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-12112
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-12095
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-12129
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-13548
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11766
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11757
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11684
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11909
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11929
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11949
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11969
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11989
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-12023
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11998
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-12180
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-12610
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-12040
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-12282
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-12058
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-12075
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-12225
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-12244
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-12263
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-12301
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-12320
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-12339
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-12358
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-12377
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-12435
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-12467
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Coded value in dataset prsb03-dataelement-13549
|
|
|
Free text
prsb03-dataelement-13524
|
|
|
| Id |
prsb03-dataelement-13524 (2020‑09‑04 13:54:04)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Free text in dataset prsb03-dataelement-13550
|
|
|
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.
|
| 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 |
|
Used by
|
0 transactions, 0 templates, inherited 69 times |
| |
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 69 times |
| |
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-11356
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-11417
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-11434
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-11451
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-11468
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-13042
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-13059
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-11485
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-11502
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-11519
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-12406
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-13477
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-11730
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-11749
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-11313
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-11330
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-11347
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-11373
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-11382
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-11391
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-11400
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-12208
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-12199
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-12148
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-12165
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-11528
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-11537
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-11546
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-11555
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-11564
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-11573
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-11582
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-11591
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-11609
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-11618
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-11881
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-11628
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-11600
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-11637
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-12114
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-12097
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-12131
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-13552
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-11768
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-11759
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-11686
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-11911
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-11931
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-11951
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-11971
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-11991
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-12025
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-12000
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-12182
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-12612
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-12042
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-12284
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-12060
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-12077
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-12227
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-12246
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-12265
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-12303
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-12322
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-12341
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-12360
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-12379
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-12437
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-12469
|
|
|
Contact details
prsb03-dataelement-11297
|
|
|
| Id |
prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited 69 times |
| |
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11357
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11418
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11435
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11452
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11469
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-13043
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-13060
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11486
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11503
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11520
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-12407
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-13478
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11731
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11750
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11314
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11331
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11348
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11374
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11383
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11392
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11401
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-12209
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-12200
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-12149
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-12166
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11529
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11538
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11547
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11556
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11565
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11574
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11583
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11592
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11610
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11619
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11882
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11629
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11601
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11638
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-12115
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-12098
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-12132
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-13553
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11769
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11760
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11687
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11912
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11932
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11952
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11972
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11992
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-12026
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-12001
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-12183
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-12613
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-12043
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-12285
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-12061
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-12078
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-12228
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-12247
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-12266
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-12304
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-12323
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-12342
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-12361
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-12380
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-12438
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-12470
|
|
|
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 |
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
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 |
|
|
|
Location
prsb03-dataelement-13631
|
|
|
|
|
Coded value
prsb03-dataelement-13632
|
|
|
|
|
Free text
prsb03-dataelement-13633
|
|
|
|
|
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.
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Contact details
prsb03-dataelement-13637
|
|
|
|
|
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 |
|
|
|
Name
prsb03-dataelement-13639
|
|
|
| Id |
prsb03-dataelement-13639 (2020‑09‑08 20:13:55)
|
| Concept inherits from |
prsb03-dataelement-13463 (2020‑09‑02 12:38:25)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
|
|
Role
prsb03-dataelement-13640
|
|
|
| Id |
prsb03-dataelement-13640 (2020‑09‑08 20:13:55)
|
| Concept inherits from |
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 |
|
|
|
Grade
prsb03-dataelement-13641
|
|
|
| Id |
prsb03-dataelement-13641 (2020‑09‑08 20:13:55)
|
| Concept inherits from |
prsb03-dataelement-13465 (2020‑09‑02 12:38:25)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Speciality
prsb03-dataelement-13642
|
|
|
|
|
Professional identifier
prsb03-dataelement-13643
|
|
|
| Id |
prsb03-dataelement-13643 (2020‑09‑08 20:13:55)
|
| Concept inherits from |
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 |
|
|
|
Organisation
prsb03-dataelement-13644
|
|
|
|
|
Contact details
prsb03-dataelement-13645
|
|
|
| Id |
prsb03-dataelement-13645 (2020‑09‑08 20:13:55)
|
| Concept inherits from |
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 |
|
|
|
Person completing record
prsb03-dataelement-13646
|
|
|
|
|
Name
prsb03-dataelement-13647
|
|
|
| Id |
prsb03-dataelement-13647 (2020‑09‑08 20:14:49)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-13648
|
|
|
| Id |
prsb03-dataelement-13648 (2020‑09‑08 20:14:49)
|
| Concept inherits from |
prsb03-dataelement-13494 (2020‑09‑02 17:10:59)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-13649
|
|
|
| Id |
prsb03-dataelement-13649 (2020‑09‑08 20:14:49)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-13650
|
|
|
|
|
Organisation
prsb03-dataelement-13651
|
|
|
|
|
Professional identifier
prsb03-dataelement-13652
|
|
|
| Id |
prsb03-dataelement-13652 (2020‑09‑08 20:14:49)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-13653
|
|
|
| Id |
prsb03-dataelement-13653 (2020‑09‑08 20:14:49)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-13654
|
|
|
| Id |
prsb03-dataelement-13654 (2020‑09‑08 20:14:49)
|
| Concept inherits from |
prsb03-dataelement-13500 (2020‑09‑02 17:10:59)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
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 |
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
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 |
|
|
|
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 |
|
| Example |
Requested |
| Example |
Authorised |
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Performing professional
prsb03-dataelement-13073
|
|
|
|
|
Name
prsb03-dataelement-13074
|
|
|
| Id |
prsb03-dataelement-13074 (2020‑05‑21 18:21:29)
|
| Concept inherits from |
prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
|
|
Role
prsb03-dataelement-13075
|
|
|
| Id |
prsb03-dataelement-13075 (2020‑05‑21 18:21:29)
|
| Concept inherits from |
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 |
|
|
|
Grade
prsb03-dataelement-13076
|
|
|
| Id |
prsb03-dataelement-13076 (2020‑05‑21 18:21:29)
|
| Concept inherits from |
prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Speciality
prsb03-dataelement-13077
|
|
|
|
|
Professional identifier
prsb03-dataelement-13078
|
|
|
| Id |
prsb03-dataelement-13078 (2020‑05‑21 18:21:29)
|
| Concept inherits from |
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 |
|
|
|
Organisation
prsb03-dataelement-13079
|
|
|
|
|
Contact details
prsb03-dataelement-13080
|
|
|
| Id |
prsb03-dataelement-13080 (2020‑05‑21 18:21:29)
|
| Concept inherits from |
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Name
prsb03-dataelement-11299
|
|
|
| Id |
prsb03-dataelement-11299 (2019‑05‑30 12:51:19)
|
| Concept inherits from |
prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
|
|
Role
prsb03-dataelement-11300
|
|
|
| Id |
prsb03-dataelement-11300 (2019‑05‑30 12:51:19)
|
| Concept inherits from |
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 |
|
|
|
Grade
prsb03-dataelement-11301
|
|
|
| Id |
prsb03-dataelement-11301 (2019‑05‑30 12:51:19)
|
| Concept inherits from |
prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Speciality
prsb03-dataelement-11302
|
|
|
|
|
Professional identifier
prsb03-dataelement-11303
|
|
|
| Id |
prsb03-dataelement-11303 (2019‑05‑30 12:51:19)
|
| Concept inherits from |
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 |
|
|
|
Organisation
prsb03-dataelement-11304
|
|
|
|
|
Contact details
prsb03-dataelement-11305
|
|
|
| Id |
prsb03-dataelement-11305 (2019‑05‑30 12:51:19)
|
| Concept inherits from |
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 |
|
|
|
Person completing record
prsb03-dataelement-11306
|
|
|
|
|
Name
prsb03-dataelement-11307
|
|
|
| Id |
prsb03-dataelement-11307 (2019‑05‑30 12:52:15)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-11308
|
|
|
| Id |
prsb03-dataelement-11308 (2019‑05‑30 12:52:15)
|
| Concept inherits from |
prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-11309
|
|
|
| Id |
prsb03-dataelement-11309 (2019‑05‑30 12:52:15)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-11310
|
|
|
|
|
Organisation
prsb03-dataelement-11311
|
|
|
|
|
Professional identifier
prsb03-dataelement-11312
|
|
|
| Id |
prsb03-dataelement-11312 (2019‑05‑30 12:52:15)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-11313
|
|
|
| Id |
prsb03-dataelement-11313 (2019‑05‑30 12:52:15)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-11314
|
|
|
| Id |
prsb03-dataelement-11314 (2019‑05‑30 12:52:15)
|
| Concept inherits from |
prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
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 |
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Coded value in dataset prsb03-dataelement-13632
|
|
|
Free text
prsb03-dataelement-13454
|
|
|
| Id |
prsb03-dataelement-13454 (2020‑08‑27 16:56:28)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Free text in dataset prsb03-dataelement-13633
|
|
|
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.
|
|
|
Coded value
prsb03-dataelement-13628
|
|
|
|
|
Free text
prsb03-dataelement-13629
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
Name
prsb03-dataelement-11316
|
|
|
| Id |
prsb03-dataelement-11316 (2019‑05‑30 12:53:54)
|
| Concept inherits from |
prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
|
|
Role
prsb03-dataelement-11317
|
|
|
| Id |
prsb03-dataelement-11317 (2019‑05‑30 12:53:54)
|
| Concept inherits from |
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 |
|
|
|
Grade
prsb03-dataelement-11318
|
|
|
| Id |
prsb03-dataelement-11318 (2019‑05‑30 12:53:54)
|
| Concept inherits from |
prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Speciality
prsb03-dataelement-11319
|
|
|
|
|
Professional identifier
prsb03-dataelement-11320
|
|
|
| Id |
prsb03-dataelement-11320 (2019‑05‑30 12:53:54)
|
| Concept inherits from |
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 |
|
|
|
Organisation
prsb03-dataelement-11321
|
|
|
|
|
Contact details
prsb03-dataelement-11322
|
|
|
| Id |
prsb03-dataelement-11322 (2019‑05‑30 12:53:54)
|
| Concept inherits from |
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 |
|
|
|
Person completing record
prsb03-dataelement-11323
|
|
|
|
|
Name
prsb03-dataelement-11324
|
|
|
| Id |
prsb03-dataelement-11324 (2019‑05‑30 12:55:19)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-11325
|
|
|
| Id |
prsb03-dataelement-11325 (2019‑05‑30 12:55:19)
|
| Concept inherits from |
prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-11326
|
|
|
| Id |
prsb03-dataelement-11326 (2019‑05‑30 12:55:19)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-11327
|
|
|
|
|
Organisation
prsb03-dataelement-11328
|
|
|
|
|
Professional identifier
prsb03-dataelement-11329
|
|
|
| Id |
prsb03-dataelement-11329 (2019‑05‑30 12:55:19)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-11330
|
|
|
| Id |
prsb03-dataelement-11330 (2019‑05‑30 12:55:19)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-11331
|
|
|
| Id |
prsb03-dataelement-11331 (2019‑05‑30 12:55:19)
|
| Concept inherits from |
prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
Advance decision to refuse treatment (ADRT)
prsb03-dataelement-10428
|
|
|
| Id |
prsb03-dataelement-10428 (2018‑10‑31)
|
| Description |
Details of the person's ADRT status. |
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
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 |
|
|
|
Location
prsb03-dataelement-13480
|
|
|
|
|
Coded value
prsb03-dataelement-13481
|
|
|
|
|
Free text
prsb03-dataelement-13482
|
|
|
|
|
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.
|
|
|
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 |
|
|
|
Free text
prsb03-dataelement-13504
|
|
|
|
|
Advance decision to refuse treatment (ADRT)
prsb03-dataelement-13501
|
|
|
| Id |
prsb03-dataelement-13501 (2020‑09‑02 17:31:20) 0.1
|
| Concept inherits from |
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 |
|
|
|
Performing professional
prsb03-dataelement-13484
|
|
|
|
|
Name
prsb03-dataelement-13485
|
|
|
| Id |
prsb03-dataelement-13485 (2020‑09‑02 17:08:45)
|
| Concept inherits from |
prsb03-dataelement-13463 (2020‑09‑02 12:38:25)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
|
|
Role
prsb03-dataelement-13486
|
|
|
| Id |
prsb03-dataelement-13486 (2020‑09‑02 17:08:45)
|
| Concept inherits from |
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 |
|
|
|
Grade
prsb03-dataelement-13487
|
|
|
| Id |
prsb03-dataelement-13487 (2020‑09‑02 17:08:45)
|
| Concept inherits from |
prsb03-dataelement-13465 (2020‑09‑02 12:38:25)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Speciality
prsb03-dataelement-13488
|
|
|
|
|
Professional identifier
prsb03-dataelement-13489
|
|
|
| Id |
prsb03-dataelement-13489 (2020‑09‑02 17:08:45)
|
| Concept inherits from |
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 |
|
|
|
Organisation
prsb03-dataelement-13490
|
|
|
|
|
Contact details
prsb03-dataelement-13491
|
|
|
| Id |
prsb03-dataelement-13491 (2020‑09‑02 17:08:45)
|
| Concept inherits from |
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 |
|
|
|
Person completing record
prsb03-dataelement-13492
|
|
|
|
|
Name
prsb03-dataelement-13493
|
|
|
| Id |
prsb03-dataelement-13493 (2020‑09‑02 17:10:59)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Name in dataset prsb03-dataelement-13647
|
|
|
Role
prsb03-dataelement-13494
|
|
|
| Id |
prsb03-dataelement-13494 (2020‑09‑02 17:10:59)
|
| Concept inherits from |
prsb03-dataelement-13054 (2020‑04‑28 19:36:38)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Role in dataset prsb03-dataelement-13648
|
|
|
Grade
prsb03-dataelement-13495
|
|
|
| Id |
prsb03-dataelement-13495 (2020‑09‑02 17:10:59)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Grade in dataset prsb03-dataelement-13649
|
|
|
Specialty
prsb03-dataelement-13496
|
|
|
| Id |
prsb03-dataelement-13496 (2020‑09‑02 17:10:59)
|
| Concept inherits from |
prsb03-dataelement-13056 (2020‑04‑28 19:36:38)
|
| Description |
The main specialty of the person completing the record. |
| FHIR |
PractitionerRole.specialty |
|
| Relationship |
|
| Rationale |
PractitionerRole.speciality |
| Operationalization |
NHS data dictionary :-
Activity treatment function code
|
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-13650
|
|
|
Organisation
prsb03-dataelement-13497
|
|
|
| Id |
prsb03-dataelement-13497 (2020‑09‑02 17:10:59)
|
| Concept inherits from |
prsb03-dataelement-13057 (2020‑04‑28 19:36:38)
|
| Description |
The organisation the person completing the record works for. |
| Relationship |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-13651
|
|
|
Professional identifier
prsb03-dataelement-13498
|
|
|
| Id |
prsb03-dataelement-13498 (2020‑09‑02 17:10:59)
|
| Concept inherits from |
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.
|
| 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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Date completed
prsb03-dataelement-13499
|
|
|
| Id |
prsb03-dataelement-13499 (2020‑09‑02 17:10:59)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-13653
|
|
|
Contact details
prsb03-dataelement-13500
|
|
|
| Id |
prsb03-dataelement-13500 (2020‑09‑02 17:10:59)
|
| Concept inherits from |
prsb03-dataelement-13060 (2020‑04‑28 19:36:38)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-13654
|
|
|
Performing Professional
prsb03-dataelement-13483
|
|
|
| Id |
prsb03-dataelement-13483 (2020‑09‑02 17:04:45) 0.1
|
| Concept inherits from |
prsb03-dataelement-10460 (2018‑10‑31)
|
| Description |
Details of the professional performing the examination (including name and role). |
| Operationalization |
Free text |
| Value Domain |
|
|
|
Date
prsb03-dataelement-11693
|
|
|
| Id |
prsb03-dataelement-11693 (2019‑05‑31 12:53:37)
|
| Concept inherits from |
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 |
|
|
|
Location
prsb03-dataelement-11694
|
|
|
|
|
Performing professional
prsb03-dataelement-11332
|
|
|
|
|
Name
prsb03-dataelement-11333
|
|
|
| Id |
prsb03-dataelement-11333 (2019‑05‑30 12:57:23)
|
| Concept inherits from |
prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
|
|
Role
prsb03-dataelement-11334
|
|
|
| Id |
prsb03-dataelement-11334 (2019‑05‑30 12:57:23)
|
| Concept inherits from |
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 |
|
|
|
Grade
prsb03-dataelement-11335
|
|
|
| Id |
prsb03-dataelement-11335 (2019‑05‑30 12:57:23)
|
| Concept inherits from |
prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Speciality
prsb03-dataelement-11336
|
|
|
|
|
Professional identifier
prsb03-dataelement-11337
|
|
|
| Id |
prsb03-dataelement-11337 (2019‑05‑30 12:57:23)
|
| Concept inherits from |
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 |
|
|
|
Organisation
prsb03-dataelement-11338
|
|
|
|
|
Contact details
prsb03-dataelement-11339
|
|
|
| Id |
prsb03-dataelement-11339 (2019‑05‑30 12:57:23)
|
| Concept inherits from |
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 |
|
|
|
Person completing record
prsb03-dataelement-11340
|
|
|
|
|
Name
prsb03-dataelement-11341
|
|
|
| Id |
prsb03-dataelement-11341 (2019‑05‑30 12:58:08)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-11342
|
|
|
| Id |
prsb03-dataelement-11342 (2019‑05‑30 12:58:08)
|
| Concept inherits from |
prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-11343
|
|
|
| Id |
prsb03-dataelement-11343 (2019‑05‑30 12:58:08)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-11344
|
|
|
|
|
Organisation
prsb03-dataelement-11345
|
|
|
|
|
Professional identifier
prsb03-dataelement-11346
|
|
|
| Id |
prsb03-dataelement-11346 (2019‑05‑30 12:58:08)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-11347
|
|
|
| Id |
prsb03-dataelement-11347 (2019‑05‑30 12:58:08)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-11348
|
|
|
| Id |
prsb03-dataelement-11348 (2019‑05‑30 12:58:08)
|
| Concept inherits from |
prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
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
|
|
|
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 |
|
|
|
Child Protection Plan
prsb03-dataelement-10433
|
|
|
|
|
Local Authority
prsb03-dataelement-10434
|
|
|
|
|
Safeguarding
prsb03-dataelement-271
|
|
|
|
|
Safeguarding concerns
prsb03-dataelement-10821
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Location
prsb03-dataelement-10173
|
|
|
|
|
Coded value
prsb03-dataelement-13437
|
|
|
|
|
Free text
prsb03-dataelement-13438
|
|
|
|
|
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 |
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
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 |
|
|
|
Safeguarding concerns
prsb03-dataelement-10171
|
|
|
|
|
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 |
|
|
|
Free text
prsb03-dataelement-13757
|
|
|
|
|
Performing professional
prsb03-dataelement-11358
|
|
|
| Id |
prsb03-dataelement-11358 (2019‑05‑30 13:51:50)
|
| Description |
The professional who identified the safeguarding concerns. |
| Relationship |
|
|
|
Name
prsb03-dataelement-11359
|
|
|
| Id |
prsb03-dataelement-11359 (2019‑05‑30 13:52:16)
|
| Concept inherits from |
prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
|
|
Role
prsb03-dataelement-11360
|
|
|
| Id |
prsb03-dataelement-11360 (2019‑05‑30 13:52:16)
|
| Concept inherits from |
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 |
|
|
|
Grade
prsb03-dataelement-11361
|
|
|
| Id |
prsb03-dataelement-11361 (2019‑05‑30 13:52:16)
|
| Concept inherits from |
prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Speciality
prsb03-dataelement-11362
|
|
|
|
|
Professional identifier
prsb03-dataelement-11363
|
|
|
| Id |
prsb03-dataelement-11363 (2019‑05‑30 13:52:16)
|
| Concept inherits from |
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 |
|
|
|
Organisation
prsb03-dataelement-11364
|
|
|
|
|
Contact details
prsb03-dataelement-11365
|
|
|
| Id |
prsb03-dataelement-11365 (2019‑05‑30 13:52:16)
|
| Concept inherits from |
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 |
|
|
|
Person completing record
prsb03-dataelement-11366
|
|
|
|
|
Name
prsb03-dataelement-11367
|
|
|
| Id |
prsb03-dataelement-11367 (2019‑05‑30 13:53:34)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-11368
|
|
|
| Id |
prsb03-dataelement-11368 (2019‑05‑30 13:53:34)
|
| Concept inherits from |
prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-11369
|
|
|
| Id |
prsb03-dataelement-11369 (2019‑05‑30 13:53:34)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-11370
|
|
|
|
|
Organisation
prsb03-dataelement-11371
|
|
|
|
|
Professional identifier
prsb03-dataelement-11372
|
|
|
| Id |
prsb03-dataelement-11372 (2019‑05‑30 13:53:34)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-11373
|
|
|
| Id |
prsb03-dataelement-11373 (2019‑05‑30 13:53:34)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-11374
|
|
|
| Id |
prsb03-dataelement-11374 (2019‑05‑30 13:53:34)
|
| Concept inherits from |
prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
Comment
prsb03-dataelement-10175
|
|
|
| Id |
prsb03-dataelement-10175 (2018‑10‑31)
|
| Description |
Further details on safeguarding concerns. |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Performing professional
prsb03-dataelement-11148
|
|
|
| Id |
prsb03-dataelement-11148 (2019‑05‑24 11:51:30)
|
| Description |
The professional identifying the safeguarding concern. |
Used by
|
0 transactions, 0 templates, inherited 5 times |
| |
|
|
|
Name
prsb03-dataelement-11149
|
|
|
| Id |
prsb03-dataelement-11149 (2019‑05‑24 11:51:53)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited 5 times |
| |
This concept is inherited by concept
Name in dataset prsb03-dataelement-11179
This concept is inherited by concept
Name in dataset prsb03-dataelement-11199
This concept is inherited by concept
Name in dataset prsb03-dataelement-11219
This concept is inherited by concept
Name in dataset prsb03-dataelement-11239
This concept is inherited by concept
Name in dataset prsb03-dataelement-11261
|
|
|
Role
prsb03-dataelement-11150
|
|
|
| Id |
prsb03-dataelement-11150 (2019‑05‑24 11:51:53)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited 5 times |
| |
This concept is inherited by concept
Role in dataset prsb03-dataelement-11180
This concept is inherited by concept
Role in dataset prsb03-dataelement-11200
This concept is inherited by concept
Role in dataset prsb03-dataelement-11220
This concept is inherited by concept
Role in dataset prsb03-dataelement-11240
This concept is inherited by concept
Role in dataset prsb03-dataelement-11262
|
|
|
Speciality
prsb03-dataelement-11151
|
|
|
| Id |
prsb03-dataelement-11151 (2019‑05‑24 11:51:53)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited 5 times |
| |
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-11181
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-11201
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-11221
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-11241
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-11263
|
|
|
Team
prsb03-dataelement-11152
|
|
|
| Id |
prsb03-dataelement-11152 (2019‑05‑24 11:51:53)
|
| Concept inherits from |
prsb03-dataelement-11048 (2019‑05‑24 11:18:10)
|
| Description |
The name of the team. |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited 5 times |
| |
This concept is inherited by concept
Team in dataset prsb03-dataelement-11182
This concept is inherited by concept
Team in dataset prsb03-dataelement-11202
This concept is inherited by concept
Team in dataset prsb03-dataelement-11222
This concept is inherited by concept
Team in dataset prsb03-dataelement-11242
This concept is inherited by concept
Team in dataset prsb03-dataelement-11264
|
|
|
Organisation
prsb03-dataelement-11153
|
|
|
| Id |
prsb03-dataelement-11153 (2019‑05‑24 11:51:53)
|
| Concept inherits from |
prsb03-dataelement-11049 (2019‑05‑24 11:18:10)
|
| Description |
The name of the organisation. |
Used by
|
0 transactions, 0 templates, inherited 5 times |
| |
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11183
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11203
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11223
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11243
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11265
|
|
|
Contact details
prsb03-dataelement-11154
|
|
|
| Id |
prsb03-dataelement-11154 (2019‑05‑24 11:51:53)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited 5 times |
| |
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11184
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11204
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11224
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11244
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11266
|
|
|
Professional identifier
prsb03-dataelement-11167
|
|
|
| Id |
prsb03-dataelement-11167 (2019‑05‑28 17:18:30)
|
| Concept inherits from |
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.
|
| FHIR |
PractitionerRole.Practitioner.identifier (local) Practitioner.identifer (professional) |
|
| Value Domain |
|
Used by
|
0 transactions, 0 templates, inherited 5 times |
| |
|
|
|
Start date
prsb03-dataelement-11155
|
|
|
| Id |
prsb03-dataelement-11155 (2019‑05‑24 11:51:53)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited 5 times |
| |
This concept is inherited by concept
Start date in dataset prsb03-dataelement-11186
This concept is inherited by concept
Start date in dataset prsb03-dataelement-11206
This concept is inherited by concept
Start date in dataset prsb03-dataelement-11226
This concept is inherited by concept
Start date in dataset prsb03-dataelement-11246
This concept is inherited by concept
Start date in dataset prsb03-dataelement-11268
|
|
|
End date
prsb03-dataelement-11156
|
|
|
| Id |
prsb03-dataelement-11156 (2019‑05‑24 11:51:53)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited 5 times |
| |
This concept is inherited by concept
End date in dataset prsb03-dataelement-11187
This concept is inherited by concept
End date in dataset prsb03-dataelement-11207
This concept is inherited by concept
End date in dataset prsb03-dataelement-11227
This concept is inherited by concept
End date in dataset prsb03-dataelement-11247
This concept is inherited by concept
End date in dataset prsb03-dataelement-11269
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 5 times |
| |
|
|
|
Person completing record
prsb03-dataelement-319
|
|
|
| Id |
prsb03-dataelement-319 (2018‑10‑31)
|
| Description |
Details of the person completing the record. |
Used by
|
0 transactions, 0 templates, inherited 14 times |
| |
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 15 times |
| |
This concept is inherited by concept
Name in dataset prsb03-dataelement-11190
This concept is inherited by concept
Name in dataset prsb03-dataelement-11024
This concept is inherited by concept
Name in dataset prsb03-dataelement-11210
This concept is inherited by concept
Name in dataset prsb03-dataelement-11064
This concept is inherited by concept
Name in dataset prsb03-dataelement-11230
This concept is inherited by concept
Name in dataset prsb03-dataelement-11083
This concept is inherited by concept
Name in dataset prsb03-dataelement-11250
This concept is inherited by concept
Name in dataset prsb03-dataelement-11102
This concept is inherited by concept
Name in dataset prsb03-dataelement-11121
This concept is inherited by concept
Name in dataset prsb03-dataelement-11140
This concept is inherited by concept
Name in dataset prsb03-dataelement-11272
This concept is inherited by concept
Name in dataset prsb03-dataelement-11170
This concept is inherited by concept
Name in dataset prsb03-dataelement-10997
This concept is inherited by concept
Name in dataset prsb03-dataelement-11006
This concept is inherited by concept
Name in dataset prsb03-dataelement-11015
|
|
|
Role
prsb03-dataelement-10220
|
|
|
| Id |
prsb03-dataelement-10220 (2018‑10‑31)
|
| Description |
The role of the person completing record. |
| 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 |
|
Used by
|
0 transactions, 0 templates, inherited 15 times |
| |
This concept is inherited by concept
Role in dataset prsb03-dataelement-11191
This concept is inherited by concept
Role in dataset prsb03-dataelement-11025
This concept is inherited by concept
Role in dataset prsb03-dataelement-11211
This concept is inherited by concept
Role in dataset prsb03-dataelement-11065
This concept is inherited by concept
Role in dataset prsb03-dataelement-11231
This concept is inherited by concept
Role in dataset prsb03-dataelement-11084
This concept is inherited by concept
Role in dataset prsb03-dataelement-11251
This concept is inherited by concept
Role in dataset prsb03-dataelement-11103
This concept is inherited by concept
Role in dataset prsb03-dataelement-11122
This concept is inherited by concept
Role in dataset prsb03-dataelement-11141
This concept is inherited by concept
Role in dataset prsb03-dataelement-11273
This concept is inherited by concept
Role in dataset prsb03-dataelement-11171
This concept is inherited by concept
Role in dataset prsb03-dataelement-10998
This concept is inherited by concept
Role in dataset prsb03-dataelement-11007
This concept is inherited by concept
Role in dataset prsb03-dataelement-11016
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 15 times |
| |
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11192
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11026
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11212
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11066
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11232
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11085
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11252
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11104
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11123
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11142
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11274
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11172
This concept is inherited by concept
Grade in dataset prsb03-dataelement-10999
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11008
This concept is inherited by concept
Grade in dataset prsb03-dataelement-11017
|
|
|
Specialty
prsb03-dataelement-10222
|
|
|
| Id |
prsb03-dataelement-10222 (2018‑10‑31)
|
| Description |
The main specialty of the person completing the record. |
| FHIR |
PractitionerRole.specialty |
|
| Operationalization |
The main clinical specialty as held on the source system. |
| Value Domain |
|
Used by
|
0 transactions, 0 templates, inherited 15 times |
| |
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-11193
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-11027
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-11213
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-11067
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-11233
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-11086
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-11253
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-11105
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-11124
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-11143
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-11275
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-11173
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-11000
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-11009
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-11018
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 15 times |
| |
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11194
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11031
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11214
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11071
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11234
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11090
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11254
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11109
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11128
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11147
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11276
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11174
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11004
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11013
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11022
|
|
|
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.
|
| FHIR |
PractitionerRole.Practitioner.identifier (local) Practitioner.identifer (professional) |
|
| Value Domain |
|
Used by
|
0 transactions, 0 templates, inherited 16 times |
| |
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 15 times |
| |
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-11196
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-11029
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-11216
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-11069
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-11236
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-11088
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-11256
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-11107
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-11126
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-11145
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-11278
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-11176
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-11002
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-11011
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-11020
|
|
|
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.
|
| 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 |
|
Used by
|
0 transactions, 0 templates, inherited 15 times |
| |
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11197
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11030
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11217
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11070
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11237
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11089
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11257
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11108
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11127
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11146
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11279
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11177
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11003
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11012
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11021
|
|
|
Looked after child
prsb03-dataelement-10797
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
Local authority
prsb03-dataelement-10799
|
|
|
|
|
Coded value
prsb03-dataelement-13614
|
|
|
|
|
Free text
prsb03-dataelement-13615
|
|
|
|
|
Person completing record
prsb03-dataelement-11375
|
|
|
|
|
Name
prsb03-dataelement-11376
|
|
|
| Id |
prsb03-dataelement-11376 (2019‑05‑30 13:54:40)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-11377
|
|
|
| Id |
prsb03-dataelement-11377 (2019‑05‑30 13:54:40)
|
| Concept inherits from |
prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-11378
|
|
|
| Id |
prsb03-dataelement-11378 (2019‑05‑30 13:54:40)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-11379
|
|
|
|
|
Organisation
prsb03-dataelement-11380
|
|
|
|
|
Professional identifier
prsb03-dataelement-11381
|
|
|
| Id |
prsb03-dataelement-11381 (2019‑05‑30 13:54:40)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-11382
|
|
|
| Id |
prsb03-dataelement-11382 (2019‑05‑30 13:54:40)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-11383
|
|
|
| Id |
prsb03-dataelement-11383 (2019‑05‑30 13:54:40)
|
| Concept inherits from |
prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
Person completing record
prsb03-dataelement-11169
|
|
|
|
|
Name
prsb03-dataelement-11170
|
|
|
| Id |
prsb03-dataelement-11170 (2019‑05‑28 17:43:26)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-11171
|
|
|
| Id |
prsb03-dataelement-11171 (2019‑05‑28 17:43:26)
|
| Concept inherits from |
prsb03-dataelement-10220 (2018‑10‑31)
|
| Description |
The role of the person completing record. |
| 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 |
|
|
|
Grade
prsb03-dataelement-11172
|
|
|
| Id |
prsb03-dataelement-11172 (2019‑05‑28 17:43:26)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-11173
|
|
|
| Id |
prsb03-dataelement-11173 (2019‑05‑28 17:43:26)
|
| Concept inherits from |
prsb03-dataelement-10222 (2018‑10‑31)
|
| Description |
The main specialty of the person completing the record. |
| FHIR |
PractitionerRole.specialty |
|
| Operationalization |
The main clinical specialty as held on the source system. |
| Value Domain |
|
|
|
Organisation
prsb03-dataelement-11174
|
|
|
| Id |
prsb03-dataelement-11174 (2019‑05‑28 17:43:26)
|
| Concept inherits from |
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 |
|
|
|
Professional identifier
prsb03-dataelement-11175
|
|
|
| Id |
prsb03-dataelement-11175 (2019‑05‑28 17:43:26)
|
| Concept inherits from |
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.
|
| FHIR |
PractitionerRole.Practitioner.identifier (local) Practitioner.identifer (professional) |
|
| Value Domain |
|
|
|
Date completed
prsb03-dataelement-11176
|
|
|
|
|
Contact details
prsb03-dataelement-11177
|
|
|
| Id |
prsb03-dataelement-11177 (2019‑05‑28 17:43:26)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Person completing record
prsb03-dataelement-11168
|
|
|
| Id |
prsb03-dataelement-11168 (2019‑05‑28 17:40:50)
|
| Concept inherits from |
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 |
|
|
|
Person completing record
prsb03-dataelement-10996
|
|
|
|
|
Name
prsb03-dataelement-10997
|
|
|
| Id |
prsb03-dataelement-10997 (2019‑05‑24 10:56:48)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-10998
|
|
|
| Id |
prsb03-dataelement-10998 (2019‑05‑24 10:56:48)
|
| Concept inherits from |
prsb03-dataelement-10220 (2018‑10‑31)
|
| Description |
The role of the person completing record. |
| 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 |
|
|
|
Grade
prsb03-dataelement-10999
|
|
|
| Id |
prsb03-dataelement-10999 (2019‑05‑24 10:56:48)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-11000
|
|
|
| Id |
prsb03-dataelement-11000 (2019‑05‑24 10:56:48)
|
| Concept inherits from |
prsb03-dataelement-10222 (2018‑10‑31)
|
| Description |
The main specialty of the person completing the record. |
| FHIR |
PractitionerRole.specialty |
|
| Operationalization |
The main clinical specialty as held on the source system. |
| Value Domain |
|
|
|
Professional identifier
prsb03-dataelement-11001
|
|
|
| Id |
prsb03-dataelement-11001 (2019‑05‑24 10:56:48)
|
| Concept inherits from |
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.
|
| FHIR |
PractitionerRole.Practitioner.identifier (local) Practitioner.identifer (professional) |
|
| Value Domain |
|
|
|
Date completed
prsb03-dataelement-11002
|
|
|
|
|
Contact details
prsb03-dataelement-11003
|
|
|
| Id |
prsb03-dataelement-11003 (2019‑05‑24 10:56:48)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Organisation
prsb03-dataelement-11004
|
|
|
| Id |
prsb03-dataelement-11004 (2019‑05‑24 10:56:48)
|
| Concept inherits from |
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 |
|
|
|
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 |
|
|
|
Child protection plan
prsb03-dataelement-10798
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
Local authority
prsb03-dataelement-10748
|
|
|
|
|
Coded value
prsb03-dataelement-13616
|
|
|
|
|
Free text
prsb03-dataelement-13617
|
|
|
|
|
Person completing record
prsb03-dataelement-11384
|
|
|
|
|
Name
prsb03-dataelement-11385
|
|
|
| Id |
prsb03-dataelement-11385 (2019‑05‑30 13:55:35)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-11386
|
|
|
| Id |
prsb03-dataelement-11386 (2019‑05‑30 13:55:35)
|
| Concept inherits from |
prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-11387
|
|
|
| Id |
prsb03-dataelement-11387 (2019‑05‑30 13:55:35)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-11388
|
|
|
|
|
Organisation
prsb03-dataelement-11389
|
|
|
|
|
Professional identifier
prsb03-dataelement-11390
|
|
|
| Id |
prsb03-dataelement-11390 (2019‑05‑30 13:55:35)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-11391
|
|
|
| Id |
prsb03-dataelement-11391 (2019‑05‑30 13:55:35)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-11392
|
|
|
| Id |
prsb03-dataelement-11392 (2019‑05‑30 13:55:35)
|
| Concept inherits from |
prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
Person completing record
prsb03-dataelement-11005
|
|
|
|
|
Name
prsb03-dataelement-11006
|
|
|
| Id |
prsb03-dataelement-11006 (2019‑05‑24 10:57:52)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-11007
|
|
|
| Id |
prsb03-dataelement-11007 (2019‑05‑24 10:57:52)
|
| Concept inherits from |
prsb03-dataelement-10220 (2018‑10‑31)
|
| Description |
The role of the person completing record. |
| 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 |
|
|
|
Grade
prsb03-dataelement-11008
|
|
|
| Id |
prsb03-dataelement-11008 (2019‑05‑24 10:57:52)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-11009
|
|
|
| Id |
prsb03-dataelement-11009 (2019‑05‑24 10:57:52)
|
| Concept inherits from |
prsb03-dataelement-10222 (2018‑10‑31)
|
| Description |
The main specialty of the person completing the record. |
| FHIR |
PractitionerRole.specialty |
|
| Operationalization |
The main clinical specialty as held on the source system. |
| Value Domain |
|
|
|
Professional identifier
prsb03-dataelement-11010
|
|
|
| Id |
prsb03-dataelement-11010 (2019‑05‑24 10:57:52)
|
| Concept inherits from |
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.
|
| FHIR |
PractitionerRole.Practitioner.identifier (local) Practitioner.identifer (professional) |
|
| Value Domain |
|
|
|
Date completed
prsb03-dataelement-11011
|
|
|
|
|
Contact details
prsb03-dataelement-11012
|
|
|
| Id |
prsb03-dataelement-11012 (2019‑05‑24 10:57:52)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Organisation
prsb03-dataelement-11013
|
|
|
| Id |
prsb03-dataelement-11013 (2019‑05‑24 10:57:52)
|
| Concept inherits from |
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 |
|
|
|
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 |
|
|
|
Unborn child protection plan
prsb03-dataelement-10923
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
Local authority
prsb03-dataelement-10926
|
|
|
|
|
Coded value
prsb03-dataelement-13618
|
|
|
|
|
Free text
prsb03-dataelement-13619
|
|
|
|
|
Person completing record
prsb03-dataelement-11393
|
|
|
|
|
Name
prsb03-dataelement-11394
|
|
|
| Id |
prsb03-dataelement-11394 (2019‑05‑30 13:56:18)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-11395
|
|
|
| Id |
prsb03-dataelement-11395 (2019‑05‑30 13:56:18)
|
| Concept inherits from |
prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-11396
|
|
|
| Id |
prsb03-dataelement-11396 (2019‑05‑30 13:56:18)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-11397
|
|
|
|
|
Organisation
prsb03-dataelement-11398
|
|
|
|
|
Professional identifier
prsb03-dataelement-11399
|
|
|
| Id |
prsb03-dataelement-11399 (2019‑05‑30 13:56:18)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-11400
|
|
|
| Id |
prsb03-dataelement-11400 (2019‑05‑30 13:56:18)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-11401
|
|
|
| Id |
prsb03-dataelement-11401 (2019‑05‑30 13:56:18)
|
| Concept inherits from |
prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
Person completing record
prsb03-dataelement-11014
|
|
|
|
|
Name
prsb03-dataelement-11015
|
|
|
| Id |
prsb03-dataelement-11015 (2019‑05‑24 10:58:56)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-11016
|
|
|
| Id |
prsb03-dataelement-11016 (2019‑05‑24 10:58:56)
|
| Concept inherits from |
prsb03-dataelement-10220 (2018‑10‑31)
|
| Description |
The role of the person completing record. |
| 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 |
|
|
|
Grade
prsb03-dataelement-11017
|
|
|
| Id |
prsb03-dataelement-11017 (2019‑05‑24 10:58:56)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-11018
|
|
|
| Id |
prsb03-dataelement-11018 (2019‑05‑24 10:58:56)
|
| Concept inherits from |
prsb03-dataelement-10222 (2018‑10‑31)
|
| Description |
The main specialty of the person completing the record. |
| FHIR |
PractitionerRole.specialty |
|
| Operationalization |
The main clinical specialty as held on the source system. |
| Value Domain |
|
|
|
Professional identifier
prsb03-dataelement-11019
|
|
|
| Id |
prsb03-dataelement-11019 (2019‑05‑24 10:58:56)
|
| Concept inherits from |
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.
|
| FHIR |
PractitionerRole.Practitioner.identifier (local) Practitioner.identifer (professional) |
|
| Value Domain |
|
|
|
Date completed
prsb03-dataelement-11020
|
|
|
|
|
Contact details
prsb03-dataelement-11021
|
|
|
| Id |
prsb03-dataelement-11021 (2019‑05‑24 10:58:56)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Organisation
prsb03-dataelement-11022
|
|
|
| Id |
prsb03-dataelement-11022 (2019‑05‑24 10:58:56)
|
| Concept inherits from |
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 |
|
|
|
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 |
|
|
|
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.
|
|
|
Referrer Details
prsb03-dataelement-10714
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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. |
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Eligibility Criteria
prsb03-dataelement-10700
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
Disability
prsb03-dataelement-10816
|
|
|
|
|
Onset date
prsb03-dataelement-10819
|
|
|
|
|
Disability code
prsb03-dataelement-10818
|
|
|
|
|
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 |
|
|
|
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.
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Professional contacts
prsb03-dataelement-452
|
|
|
|
|
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.
|
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
This concept is inherited by concept
Name in dataset prsb03-dataelement-11045
This concept is inherited by concept
Name in dataset prsb03-dataelement-11035
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
This concept is inherited by concept
Role in dataset prsb03-dataelement-11046
This concept is inherited by concept
Role in dataset prsb03-dataelement-11036
|
|
|
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 |
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-11047
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-11037
|
|
|
Team
prsb03-dataelement-10355
|
|
|
| Id |
prsb03-dataelement-10355 (2018‑10‑31)
|
| Description |
The name of the team. |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
This concept is inherited by concept
Team in dataset prsb03-dataelement-11048
This concept is inherited by concept
Team in dataset prsb03-dataelement-11038
|
|
|
Organisation
prsb03-dataelement-10356
|
|
|
| Id |
prsb03-dataelement-10356 (2018‑10‑31)
|
| Description |
The name of the organisation. |
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11049
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-11039
|
|
|
Coded value
prsb03-dataelement-13564
|
|
|
|
|
Free text
prsb03-dataelement-13565
|
|
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11050
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-11040
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
This concept is inherited by concept
Start date in dataset prsb03-dataelement-11051
This concept is inherited by concept
Start date in dataset prsb03-dataelement-11041
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
This concept is inherited by concept
End date in dataset prsb03-dataelement-11052
This concept is inherited by concept
End date in dataset prsb03-dataelement-11042
|
|
|
Personal contacts
prsb03-dataelement-445
|
|
|
|
|
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.
|
|
|
Name
prsb03-dataelement-10345
|
|
|
| Id |
prsb03-dataelement-10345 (2018‑10‑31)
|
| Description |
The name of the personal contact. |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
NHS Number in dataset prsb03-dataelement-10878
|
|
|
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 |
|
|
|
Health and care professional details
prsb03-dataelement-10912
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
IRRE
prsb03-dataelement-10649
|
|
|
|
|
Participation in research
prsb03-dataelement-168
|
|
|
|
|
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.
|
|
|
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 |
|
|
|
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 |
|
|
|
Identification code
prsb03-dataelement-10739
|
|
|
|
|
Person completing record
prsb03-dataelement-12201
|
|
|
|
|
Name
prsb03-dataelement-12202
|
|
|
| Id |
prsb03-dataelement-12202 (2019‑05‑31 16:24:35)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-12203
|
|
|
| Id |
prsb03-dataelement-12203 (2019‑05‑31 16:24:35)
|
| Concept inherits from |
prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-12204
|
|
|
| Id |
prsb03-dataelement-12204 (2019‑05‑31 16:24:35)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-12205
|
|
|
|
|
Organisation
prsb03-dataelement-12206
|
|
|
|
|
Professional identifier
prsb03-dataelement-12207
|
|
|
| Id |
prsb03-dataelement-12207 (2019‑05‑31 16:24:35)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-12208
|
|
|
| Id |
prsb03-dataelement-12208 (2019‑05‑31 16:24:35)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-12209
|
|
|
| Id |
prsb03-dataelement-12209 (2019‑05‑31 16:24:35)
|
| Concept inherits from |
prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
Referral details
prsb03-dataelement-105
|
|
|
|
|
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.
|
|
|
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 |
|
|
|
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.
|
| FHIR |
Encounter.incomingreferral |
|
|
|
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 |
|
|
|
Role
prsb03-dataelement-10972
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
Specialty
prsb03-dataelement-12410
|
|
|
|
|
Service
prsb03-dataelement-12411
|
|
|
|
|
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 |
|
|
|
Free text
prsb03-dataelement-13398
|
|
|
|
|
Organisation
prsb03-dataelement-10974
|
|
|
|
|
Coded value
prsb03-dataelement-13399
|
|
|
|
|
Free text
prsb03-dataelement-13400
|
|
|
|
|
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 |
|
|
|
Comments
prsb03-dataelement-12408
|
|
|
|
|
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 |
|
|
|
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
- Fax
- Phone
- Secure Messaging
- Secure Email
- Letter
- NHS E-Referral Service
- Self referral
|
| Value Domain |
|
|
|
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 |
|
|
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 |
|
|
|
Free text
prsb03-dataelement-13456
|
|
|
|
|
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 |
|
|
|
Clinical urgency of referral
prsb03-dataelement-10010
|
|
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Urgency in dataset prsb03-dataelement-13836
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
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.
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Specialty
prsb03-dataelement-10983
|
|
|
|
|
Service
prsb03-dataelement-12412
|
|
|
|
|
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 |
|
|
|
Free text
prsb03-dataelement-13510
|
|
|
|
|
Organisation
prsb03-dataelement-10980
|
|
|
|
|
Coded value
prsb03-dataelement-13511
|
|
|
|
|
Free text
prsb03-dataelement-13512
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Attachments in dataset prsb03-dataelement-10915
|
|
|
Reason for Referral
prsb03-dataelement-460
|
|
|
|
|
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| |
|
|
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 |
|
|
|
Free text
prsb03-dataelement-13563
|
|
|
|
|
Clinical urgency of referral
prsb03-dataelement-10361
|
|
|
|
|
Urgency
prsb03-dataelement-13836
|
|
|
|
|
Reason for urgency of referral
prsb03-dataelement-13837
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Problem list
prsb03-dataelement-12617
|
|
|
|
|
Problem list record entry
prsb03-dataelement-12618
|
|
|
| Id |
prsb03-dataelement-12618 (2019‑11‑19 13:01:28)
|
| Concept inherits from |
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.
|
|
|
Date
prsb03-dataelement-12619
|
|
|
| Id |
prsb03-dataelement-12619 (2019‑11‑19 13:01:28)
|
| Concept inherits from |
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 |
|
|
|
Performing professional
prsb03-dataelement-12620
|
|
|
|
|
Performing professional
prsb03-dataelement-12621
|
|
|
|
|
Name
prsb03-dataelement-12622
|
|
|
| Id |
prsb03-dataelement-12622 (2019‑11‑19 13:01:28)
|
| Concept inherits from |
prsb03-dataelement-12134 (2019‑05‑31 16:04:17)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
|
|
Role
prsb03-dataelement-12623
|
|
|
| Id |
prsb03-dataelement-12623 (2019‑11‑19 13:01:28)
|
| Concept inherits from |
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 |
|
|
|
Grade
prsb03-dataelement-12624
|
|
|
| Id |
prsb03-dataelement-12624 (2019‑11‑19 13:01:28)
|
| Concept inherits from |
prsb03-dataelement-12136 (2019‑05‑31 16:04:17)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Speciality
prsb03-dataelement-12625
|
|
|
|
|
Professional identifier
prsb03-dataelement-12626
|
|
|
| Id |
prsb03-dataelement-12626 (2019‑11‑19 13:01:28)
|
| Concept inherits from |
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 |
|
|
|
Organisation
prsb03-dataelement-12627
|
|
|
|
|
Contact details
prsb03-dataelement-12628
|
|
|
| Id |
prsb03-dataelement-12628 (2019‑11‑19 13:01:28)
|
| Concept inherits from |
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 |
|
|
|
Location
prsb03-dataelement-12629
|
|
|
|
|
Problem
prsb03-dataelement-12630
|
|
|
| Id |
prsb03-dataelement-12630 (2019‑11‑19 13:01:28)
|
| Concept inherits from |
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 |
|
|
|
Onset date
prsb03-dataelement-12631
|
|
|
| Id |
prsb03-dataelement-12631 (2019‑11‑19 13:01:28)
|
| Concept inherits from |
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 |
|
|
|
End Date
prsb03-dataelement-12632
|
|
|
| Id |
prsb03-dataelement-12632 (2019‑11‑19 13:01:28)
|
| Concept inherits from |
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 |
|
|
|
Stage of disease
prsb03-dataelement-12633
|
|
|
|
|
Person completing record
prsb03-dataelement-12634
|
|
|
|
|
Name
prsb03-dataelement-12635
|
|
|
| Id |
prsb03-dataelement-12635 (2019‑11‑19 13:01:28)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-12636
|
|
|
| Id |
prsb03-dataelement-12636 (2019‑11‑19 13:01:28)
|
| Concept inherits from |
prsb03-dataelement-12143 (2019‑05‑31 16:04:53)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-12637
|
|
|
| Id |
prsb03-dataelement-12637 (2019‑11‑19 13:01:28)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-12638
|
|
|
|
|
Organisation
prsb03-dataelement-12639
|
|
|
|
|
Professional identifier
prsb03-dataelement-12640
|
|
|
| Id |
prsb03-dataelement-12640 (2019‑11‑19 13:01:28)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-12641
|
|
|
| Id |
prsb03-dataelement-12641 (2019‑11‑19 13:01:28)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-12642
|
|
|
| Id |
prsb03-dataelement-12642 (2019‑11‑19 13:01:28)
|
| Concept inherits from |
prsb03-dataelement-12149 (2019‑05‑31 16:04:53)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
Person completing record
prsb03-dataelement-12643
|
|
|
| Id |
prsb03-dataelement-12643 (2019‑11‑19 13:01:28)
|
| Concept inherits from |
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 |
|
|
|
Comment
prsb03-dataelement-12644
|
|
|
| Id |
prsb03-dataelement-12644 (2019‑11‑19 13:01:28)
|
| Concept inherits from |
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 |
|
|
|
Problem
prsb03-dataelement-12645
|
|
|
| Id |
prsb03-dataelement-12645 (2019‑11‑19 13:04:13)
|
| Concept inherits from |
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 |
|
|
|
Contacts with professionals
prsb03-dataelement-169
|
|
|
|
|
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.
|
|
|
Date of contact
prsb03-dataelement-10069
|
|
|
| Id |
prsb03-dataelement-10069 (2018‑10‑31)
|
| Description |
Date and time of the contact. |
|
|
| Operationalization |
Date and time. |
| Value Domain |
|
| Property |
| Timestamp precision |
| at least day, month and year, hour and minute |
|
|
|
Location of contact
prsb03-dataelement-10075
|
|
|
|
|
Coded value
prsb03-dataelement-13513
|
|
|
|
|
Free text
prsb03-dataelement-13514
|
|
|
| Id |
prsb03-dataelement-13514 (2020‑09‑03 18:04:13)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Free text in dataset prsb03-dataelement-13963
|
|
|
Seen by
prsb03-dataelement-10077
|
|
|
|
|
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 |
|
|
|
Role
prsb03-dataelement-13758
|
|
|
|
|
Free text
prsb03-dataelement-13516
|
|
|
|
|
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).
|
| FHIR |
Encounter.participant |
|
|
|
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 |
|
|
|
Role
prsb03-dataelement-10989
|
|
|
|
|
Location type
prsb03-dataelement-10076
|
|
|
|
|
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 |
|
|
|
Contact type
prsb03-dataelement-10070
|
|
|
| Id |
prsb03-dataelement-10070 (2018‑10‑31)
|
| Description |
Type of contact e.g. GP consultation, outpatient attendance |
|
|
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Consultation method
prsb03-dataelement-10071
|
|
|
| Id |
prsb03-dataelement-10071 (2018‑10‑31)
|
| Description |
Consultation method used e.g. face to face, telephone |
| FHIR |
Handled as text in the transfer of care |
|
| Operationalization |
NHS data dictionary -
Consultation medium
|
| Value Domain |
|
| Property |
|
|
|
Specialty
prsb03-dataelement-10073
|
|
|
| Id |
prsb03-dataelement-10073 (2018‑10‑31)
|
| Description |
The specialty e.g. physiotherapy, oncology, mental health etc |
| 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 |
|
|
|
Service
prsb03-dataelement-10074
|
|
|
| Id |
prsb03-dataelement-10074 (2018‑10‑31)
|
| Description |
The service that was provided. |
| FHIR |
Encounter.Appointment.servicetype |
|
| Operationalization |
SNOMED CT :- 1127531000000102 |Services simple reference set (foundation metadata
concept)|
|
| Value Domain |
|
|
|
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)
|
| FHIR |
Encounter.participant |
|
|
|
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 |
|
|
|
Role
prsb03-dataelement-10991
|
|
|
|
|
Outcome of contact
prsb03-dataelement-10080
|
|
|
| Id |
prsb03-dataelement-10080 (2018‑10‑31)
|
| Description |
This records the outcome of the contact. |
| FHIR |
Handled as text in the transfer of care |
|
| Operationalization |
|
| Value Domain |
|
| Property |
|
|
|
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).
|
| FHIR |
Encounter.participant |
|
| Operationalization |
NHS data dictionary : -
Person full name
|
| Value Domain |
|
| Property |
|
|
|
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 |
|
|
|
Organisation address
prsb03-dataelement-10713
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Role in dataset prsb03-dataelement-13758
|
|
|
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 |
|
|
|
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 |
|
|
|
Professional identifier
prsb03-dataelement-10711
|
|
|
|
|
Admission details
prsb03-dataelement-181
|
|
|
|
|
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.
|
|
|
Date of admission
prsb03-dataelement-10085
|
|
|
| Id |
prsb03-dataelement-10085 (2018‑10‑31)
|
| Description |
Date and time the person was admitted to hospital. |
|
|
| Operationalization |
Date and time |
| Value Domain |
|
| Property |
| Timestamp precision |
| at least day, month and year, hour and minute |
|
|
|
Admitted to
prsb03-dataelement-10090
|
|
|
| Id |
prsb03-dataelement-10090 (2018‑10‑31)
|
 |
There are open issues with this item:
|
| Description |
The hospital the person was admitted to. |
|
|
Coded value
prsb03-dataelement-13380
|
|
|
|
|
Free text
prsb03-dataelement-13381
|
|
|
|
|
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)
|
|
|
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 |
|
|
|
Role
prsb03-dataelement-10993
|
|
|
|
|
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.
|
|
|
|
|
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 |
|
|
|
Free text
prsb03-dataelement-13384
|
|
|
|
|
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.
|
| FHIR |
Handled as text in the transfer of care |
|
|
|
Coded value
prsb03-dataelement-13385
|
|
|
|
|
Free text
prsb03-dataelement-13387
|
|
|
|
|
Legal status on admission
prsb03-dataelement-10083
|
|
|
|
|
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.
|
| FHIR |
Encounter.hospitalisation.admitsource |
|
|
|
Coded value
prsb03-dataelement-13388
|
|
|
|
|
Free text
prsb03-dataelement-13389
|
|
|
|
|
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 |
|
|
|
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.
|
|
|
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 |
|
|
|
Role
prsb03-dataelement-10985
|
|
|
|
|
Relationship
prsb03-dataelement-10986
|
|
|
|
|
Coded value
prsb03-dataelement-13517
|
|
|
|
|
Free text
prsb03-dataelement-13518
|
|
|
|
|
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 |
|
|
|
Specialty
prsb03-dataelement-10089
|
|
|
|
|
Coded value
prsb03-dataelement-13390
|
|
|
|
|
Free text
prsb03-dataelement-13391
|
|
|
|
|
Discharge details
prsb03-dataelement-191
|
|
|
|
|
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.
|
|
|
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 |
|
|
|
Date of discharge
prsb03-dataelement-10096
|
|
|
| Id |
prsb03-dataelement-10096 (2018‑10‑31)
|
| Description |
The date and time of discharge |
|
|
| Operationalization |
Date and time |
| Value Domain |
|
| Property |
| Timestamp precision |
| at least day, month and year, hour and minute |
|
|
|
Discharge location
prsb03-dataelement-10095
|
|
|
|
|
Discharging consultant
prsb03-dataelement-10093
|
|
|
| Id |
prsb03-dataelement-10093 (2018‑10‑31)
|
| Description |
The consultant responsible for the person at time of discharge. |
| FHIR |
Encounter.Prartitioner.PractitionerRole.identifier (local ID) Encounter.Prartitioner.PractitionerRole.code
Encounter.Prartitioner.Practitioner.identifier Encounter.Prartitioner.PractitionerRole.Practitioner.name
|
|
|
|
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 |
|
|
|
Role
prsb03-dataelement-10995
|
|
|
|
|
Discharge destination
prsb03-dataelement-10091
|
|
|
| Id |
prsb03-dataelement-10091 (2018‑10‑31)
|
| Description |
The destination of the person on discharge. |
| FHIR |
Encounter.hospitalisation.dischargedisposition |
|
| Operationalization |
Sent as per the ECDS Emergency Care Discharge Destination code set (SNOMED CT). |
| Value Domain |
|
| Property |
|
|
|
Discharge status
prsb03-dataelement-10092
|
|
|
| Id |
prsb03-dataelement-10092 (2018‑10‑31)
|
| Description |
Patient status on discharge from emergency care. |
| FHIR |
Encounter,Subject.Observation |
|
| Operationalization |
Sent as per the ECDS Emergency Care DischargeStatus code set (SNOMED CT): |
| Value Domain |
|
|
|
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.
|
| FHIR |
Handled as text in the transfer of care |
|
|
|
Coded value
prsb03-dataelement-13393
|
|
|
|
|
Free text
prsb03-dataelement-13394
|
|
|
|
|
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. |
|
|
Coded value
prsb03-dataelement-13395
|
|
|
|
|
Free text
prsb03-dataelement-13396
|
|
|
|
|
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 |
|
|
|
Legal status on discharge
prsb03-dataelement-10097
|
|
|
|
|
Discharge destination
prsb03-dataelement-10099
|
|
|
|
|
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.
|
| FHIR |
A code from the NHS Data Dictionary Discharge Destination |
|
| Operationalization |
NHS data dictionary -
Discharge destination.
|
| Value Domain |
|
| Property |
|
|
|
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. |
| 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 |
|
|
|
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 |
|
|
|
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
|
|
|
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 |
|
|
|
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
|
|
|
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 |
|
|
|
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 |
|
|
|
Emergency Care Attendance
prsb03-dataelement-379
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Discharge status
prsb03-dataelement-10284
|
|
|
|
|
Location
prsb03-dataelement-10285
|
|
|
| Id |
prsb03-dataelement-10285 (2018‑10‑31)
|
| Description |
Details of where the unscheduled care attendance took place. |
| Value Domain |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Senior reviewing clinician
prsb03-dataelement-10800
|
|
|
|
|
Senior Reviewing Clinician
prsb03-dataelement-327
|
|
|
| Id |
prsb03-dataelement-327 (2018‑10‑31)
|
| Description |
Senior Reviewing Clinician |
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Name in dataset prsb03-dataelement-12615
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
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 |
|
|
|
Referral Source
prsb03-dataelement-10290
|
|
|
|
|
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 |
|
|
|
Future appointments
prsb03-dataelement-10720
|
|
|
|
|
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.
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Clinical urgency of appointment
prsb03-dataelement-10725
|
|
|
|
|
Location of future appointment
prsb03-dataelement-10726
|
|
|
|
|
Coded value
prsb03-dataelement-13519
|
|
|
|
|
Free text
prsb03-dataelement-13520
|
|
|
|
|
Specialty
prsb03-dataelement-10727
|
|
|
| Id |
prsb03-dataelement-10727 (2019‑02‑08 16:10:35)
|
| Description |
The specialty e.g. physiotherapy, oncology, mental health etc. |
| FHIR |
Encounter.participant.individual.Practitioner.PractitionerRole.speciality (of the
consultant responsible for the encounter)
|
|
| Relationship |
|
| Operationalization |
|
| Value Domain |
|
| Property |
|
|
|
Service
prsb03-dataelement-10728
|
|
|
| Id |
prsb03-dataelement-10728 (2019‑02‑08 16:11:32)
|
| Description |
The service being provided. |
| FHIR |
Encounter.Appointment.servicetype |
|
| Relationship |
|
| Operationalization |
SNOMED CT: - 1127531000000102 |Services simple reference set (foundation metadata
concept)|
|
| Value Domain |
|
|
|
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. |
| FHIR |
Encounter.participant |
|
| Relationship |
|
|
|
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 |
|
|
|
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 |
|
|
|
Incident details
prsb03-dataelement-10887
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Injury
prsb03-dataelement-10899
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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).
|
|
|
Date
prsb03-dataelement-10447
|
|
|
|
|
Location
prsb03-dataelement-10448
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Relevant clinical risk factors
prsb03-dataelement-203
|
|
|
|
|
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.
|
|
|
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.
|
|
|
| Operationalization |
Free text |
| Value Domain |
|
|
|
Date
prsb03-dataelement-10104
|
|
|
| Id |
prsb03-dataelement-10104 (2018‑10‑31)
|
| Description |
The date on which the clinical risk factor was recorded |
| Value Domain |
|
|
|
Location
prsb03-dataelement-10105
|
|
|
| Id |
prsb03-dataelement-10105 (2018‑10‑31)
|
| Description |
The location where the clinical risk factor was recorded. |
| Value Domain |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Vaccinations
prsb03-dataelement-10685
|
|
|
|
|
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.
|
|
|
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 |
|
|
|
Location
prsb03-dataelement-10759
|
|
|
| Id |
prsb03-dataelement-10759 (2019‑03‑08 17:50:00)
|
| Description |
The location where the vaccine was administered. |
| Relationship |
|
|
|
Coded value
prsb03-dataelement-13577
|
|
|
|
|
Free text
prsb03-dataelement-13578
|
|
|
|
|
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 |
|
|
|
Performing professional
prsb03-dataelement-12184
|
|
|
| Id |
prsb03-dataelement-12184 (2019‑05‑31 16:19:14)
|
| Description |
The professional who administered the vaccine. |
| Relationship |
|
|
|
Name
prsb03-dataelement-12185
|
|
|
| Id |
prsb03-dataelement-12185 (2019‑05‑31 16:19:35)
|
| Concept inherits from |
prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Name in dataset prsb03-dataelement-13028
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Role in dataset prsb03-dataelement-13029
|
|
|
Grade
prsb03-dataelement-12187
|
|
|
| Id |
prsb03-dataelement-12187 (2019‑05‑31 16:19:35)
|
| Concept inherits from |
prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Grade in dataset prsb03-dataelement-13030
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-13031
|
|
|
Professional identifier
prsb03-dataelement-12189
|
|
|
| Id |
prsb03-dataelement-12189 (2019‑05‑31 16:19:35)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Organisation
prsb03-dataelement-12190
|
|
|
| Id |
prsb03-dataelement-12190 (2019‑05‑31 16:19:35)
|
| Concept inherits from |
prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
|
| Description |
The name of the organisation the professional works for. |
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-13033
|
|
|
Contact details
prsb03-dataelement-12191
|
|
|
| Id |
prsb03-dataelement-12191 (2019‑05‑31 16:19:35)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-13034
|
|
|
Vaccine product
prsb03-dataelement-10687
|
|
|
|
|
Coded value
prsb03-dataelement-13237
|
|
|
|
|
Free text
prsb03-dataelement-13238
|
|
|
|
|
Manufacturer
prsb03-dataelement-10698
|
|
|
|
|
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 |
|
|
|
Free text
prsb03-dataelement-13240
|
|
|
|
|
Vaccine procedure
prsb03-dataelement-10688
|
|
|
|
|
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)|
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| Value Domain |
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Free text
prsb03-dataelement-13220
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| Id |
prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
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| Description |
Free text field to be used if no code is available |
| Operationalization |
Free text |
| Value Domain |
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| Property |
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Used by
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0 transactions, 0 templates, inherited 113 times |
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This concept is inherited by concept
Free text in dataset prsb03-dataelement-13372
This concept is inherited by concept
Free text in dataset prsb03-dataelement-13361
This concept is inherited by concept
Free text in dataset prsb03-dataelement-13374
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Free text in dataset prsb03-dataelement-13364
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Free text in dataset prsb03-dataelement-13376
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Free text in dataset prsb03-dataelement-13367
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Free text in dataset prsb03-dataelement-13378
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Free text in dataset prsb03-dataelement-13370
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Free text in dataset prsb03-dataelement-13358
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Free text in dataset prsb03-dataelement-13506
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Free text in dataset prsb03-dataelement-13430
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Free text in dataset prsb03-dataelement-13508
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Free text in dataset prsb03-dataelement-13432
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Free text in dataset prsb03-dataelement-13672
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Free text in dataset prsb03-dataelement-13569
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Free text in dataset prsb03-dataelement-13452
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Free text in dataset prsb03-dataelement-13522
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Free text in dataset prsb03-dataelement-13524
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Free text in dataset prsb03-dataelement-13454
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Free text in dataset prsb03-dataelement-13629
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Free text in dataset prsb03-dataelement-13504
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Free text in dataset prsb03-dataelement-13438
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Free text in dataset prsb03-dataelement-13757
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Free text in dataset prsb03-dataelement-13615
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Free text in dataset prsb03-dataelement-13617
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Free text in dataset prsb03-dataelement-13619
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Free text in dataset prsb03-dataelement-13565
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Free text in dataset prsb03-dataelement-13398
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Free text in dataset prsb03-dataelement-13400
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Free text in dataset prsb03-dataelement-13456
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Free text in dataset prsb03-dataelement-13510
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Free text in dataset prsb03-dataelement-13512
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Free text in dataset prsb03-dataelement-13563
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Free text in dataset prsb03-dataelement-13514
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Free text in dataset prsb03-dataelement-13516
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Free text in dataset prsb03-dataelement-13381
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Free text in dataset prsb03-dataelement-13384
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Free text in dataset prsb03-dataelement-13387
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Free text in dataset prsb03-dataelement-13389
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Free text in dataset prsb03-dataelement-13518
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Free text in dataset prsb03-dataelement-13391
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Free text in dataset prsb03-dataelement-13394
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Free text in dataset prsb03-dataelement-13396
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Free text in dataset prsb03-dataelement-13520
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Free text in dataset prsb03-dataelement-13578
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Free text in dataset prsb03-dataelement-13238
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Free text in dataset prsb03-dataelement-13240
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Free text in dataset prsb03-dataelement-13234
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Free text in dataset prsb03-dataelement-13236
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Free text in dataset prsb03-dataelement-13227
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Free text in dataset prsb03-dataelement-13243
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Free text in dataset prsb03-dataelement-13245
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Free text in dataset prsb03-dataelement-13250
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Free text in dataset prsb03-dataelement-13252
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Free text in dataset prsb03-dataelement-13254
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Free text in dataset prsb03-dataelement-13256
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Free text in dataset prsb03-dataelement-13258
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Free text in dataset prsb03-dataelement-13260
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Free text in dataset prsb03-dataelement-13263
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Free text in dataset prsb03-dataelement-13275
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Free text in dataset prsb03-dataelement-13266
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Free text in dataset prsb03-dataelement-13277
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Free text in dataset prsb03-dataelement-13279
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Free text in dataset prsb03-dataelement-13270
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Free text in dataset prsb03-dataelement-13282
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Free text in dataset prsb03-dataelement-13285
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Free text in dataset prsb03-dataelement-13333
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Free text in dataset prsb03-dataelement-13292
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Free text in dataset prsb03-dataelement-13335
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Free text in dataset prsb03-dataelement-13338
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Free text in dataset prsb03-dataelement-13340
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Free text in dataset prsb03-dataelement-13347
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Free text in dataset prsb03-dataelement-13353
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Free text in dataset prsb03-dataelement-13350
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Free text in dataset prsb03-dataelement-13354
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Free text in dataset prsb03-dataelement-13567
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Free text in dataset prsb03-dataelement-13683
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Free text in dataset prsb03-dataelement-13677
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Free text in dataset prsb03-dataelement-13681
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Free text in dataset prsb03-dataelement-13726
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Free text in dataset prsb03-dataelement-13526
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Free text in dataset prsb03-dataelement-13528
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Free text in dataset prsb03-dataelement-13530
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Free text in dataset prsb03-dataelement-13446
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Free text in dataset prsb03-dataelement-13448
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Free text in dataset prsb03-dataelement-13532
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Free text in dataset prsb03-dataelement-13571
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Free text in dataset prsb03-dataelement-13573
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Free text in dataset prsb03-dataelement-13587
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Free text in dataset prsb03-dataelement-13589
This concept is inherited by concept
Free text in dataset prsb03-dataelement-13591
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Free text in dataset prsb03-dataelement-13595
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Free text in dataset prsb03-dataelement-13585
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Free text in dataset prsb03-dataelement-13442
This concept is inherited by concept
Free text in dataset prsb03-dataelement-13440
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Free text in dataset prsb03-dataelement-13555
This concept is inherited by concept
Free text in dataset prsb03-dataelement-13557
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Free text in dataset prsb03-dataelement-13559
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Free text in dataset prsb03-dataelement-13561
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Free text in dataset prsb03-dataelement-13621
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Free text in dataset prsb03-dataelement-13623
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Free text in dataset prsb03-dataelement-13625
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Free text in dataset prsb03-dataelement-13656
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Free text in dataset prsb03-dataelement-13782
This concept is inherited by concept
Free text in dataset prsb03-dataelement-13685
This concept is inherited by concept
Free text in dataset prsb03-dataelement-13699
This concept is inherited by concept
Free text in dataset prsb03-dataelement-13697
This concept is inherited by concept
Free text in dataset prsb03-dataelement-13668
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Free text in dataset prsb03-dataelement-13723
This concept is inherited by concept
Free text in dataset prsb03-dataelement-13688
This concept is inherited by concept
Free text in dataset prsb03-dataelement-13694
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Free text in dataset prsb03-dataelement-13714
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Free text in dataset prsb03-dataelement-13721
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Batch number
prsb03-dataelement-10697
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| Id |
prsb03-dataelement-10697 (2018‑12‑04 15:10:59)
|
| Description |
The batch number of the product. |
Used by
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0 transactions, 0 templates, inherited once |
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This concept is inherited by concept
Batch number in dataset prsb03-dataelement-13789
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Coded value
prsb03-dataelement-13233
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| 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 |
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Used by
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0 transactions, 0 templates, inherited once |
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This concept is inherited by concept
Coded value in dataset prsb03-dataelement-13790
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Free text
prsb03-dataelement-13234
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| Id |
prsb03-dataelement-13234 (2020‑07‑21 15:17:14)
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| Concept inherits from |
prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
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| Description |
Free text field to be used if no code is available |
| Operationalization |
Free text |
| Value Domain |
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| Property |
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Used by
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0 transactions, 0 templates, inherited once |
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This concept is inherited by concept
Free text in dataset prsb03-dataelement-13791
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Expiry date
prsb03-dataelement-10696
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| 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 |
|
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Serialisation code
prsb03-dataelement-10690
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| 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).
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Coded value
prsb03-dataelement-13235
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| Id |
prsb03-dataelement-13235 (2020‑07‑21 15:21:31)
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| Description |
The coded value for serialisation code. |
| Operationalization |
FMD code : - Derived from Falsified medicines directive |
| Value Domain |
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Free text
prsb03-dataelement-13236
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Body site
prsb03-dataelement-10691
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Coded value
prsb03-dataelement-13222
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Free text
prsb03-dataelement-13223
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| Id |
prsb03-dataelement-13223 (2020‑07‑08 17:40:09)
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| Description |
Free text field to be used if no coded text available |
| Value Domain |
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| Property |
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Used by
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0 transactions, 0 templates, inherited 17 times |
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This concept is inherited by concept
Free text in dataset prsb03-dataelement-13434
This concept is inherited by concept
Free text in dataset prsb03-dataelement-13436
This concept is inherited by concept
Free text in dataset prsb03-dataelement-13675
This concept is inherited by concept
Free text in dataset prsb03-dataelement-13482
This concept is inherited by concept
Free text in dataset prsb03-dataelement-13225
This concept is inherited by concept
Free text in dataset prsb03-dataelement-13344
This concept is inherited by concept
Free text in dataset prsb03-dataelement-13679
This concept is inherited by concept
Free text in dataset prsb03-dataelement-13728
This concept is inherited by concept
Free text in dataset prsb03-dataelement-13444
This concept is inherited by concept
Free text in dataset prsb03-dataelement-13593
This concept is inherited by concept
Free text in dataset prsb03-dataelement-13858
This concept is inherited by concept
Free text in dataset prsb03-dataelement-13846
This concept is inherited by concept
Free text in dataset prsb03-dataelement-13666
This concept is inherited by concept
Free text in dataset prsb03-dataelement-13690
This concept is inherited by concept
Free text in dataset prsb03-dataelement-13704
This concept is inherited by concept
Free text in dataset prsb03-dataelement-13702
This concept is inherited by concept
Free text in dataset prsb03-dataelement-13709
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Route
prsb03-dataelement-10692
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Coded value
prsb03-dataelement-13224
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Free text
prsb03-dataelement-13225
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Indication
prsb03-dataelement-10693
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| Id |
prsb03-dataelement-10693 (2018‑12‑04 11:38:05)
|
| Description |
The clinical indication or reason for administering the vaccine. |
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Coded value
prsb03-dataelement-13226
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|
| 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 |
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Free text
prsb03-dataelement-13227
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Dose amount
prsb03-dataelement-10694
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Coded value
prsb03-dataelement-13228
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| Id |
prsb03-dataelement-13228 (2020‑07‑15 18:42:20)
|
| Description |
Amount of vaccine administered. |
| Operationalization |
SNOMED CT : - dm+d |
| Value Domain |
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Value
prsb03-dataelement-13838
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|
| Id |
prsb03-dataelement-13838 (2020‑12‑28 22:49:54)
|
| Description |
The amount of vaccine administered |
| Relationship |
|
| Operationalization |
Free text |
| Value Domain |
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Units of measure
prsb03-dataelement-13839
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| 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 |
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| Property |
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Free text
prsb03-dataelement-13229
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| Id |
prsb03-dataelement-13229 (2020‑07‑15 19:30:33)
|
| Description |
Amount of vaccine administered. |
| Relationship |
|
| Operationalization |
Free text |
| Value Domain |
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| Property |
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Used by
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0 transactions, 0 templates, inherited 2 times |
| |
This concept is inherited by concept
Free text in dataset prsb03-dataelement-13658
This concept is inherited by concept
Free text in dataset prsb03-dataelement-13660
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Dose sequence
prsb03-dataelement-10824
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| Id |
prsb03-dataelement-10824 (2019‑03‑21 13:38:54)
|
| Description |
Nominal position in a series of vaccines. |
| Relationship |
|
| Operationalization |
Numeric value |
| Value Domain |
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| Property |
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Outcome status
prsb03-dataelement-10838
|
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|
| Id |
prsb03-dataelement-10838 (2019‑03‑26 12:32:46)
|
| Description |
Whether the vaccine was administered or not, including the reason why |
| Relationship |
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Not given flag
prsb03-dataelement-13230
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|
| 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 |
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Vaccination situation (not given reason)
prsb03-dataelement-13231
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| Id |
prsb03-dataelement-13231 (2020‑07‑16 15:00:05)
|
| Description |
The reason why a vaccination was not administered. |
| Operationalization |
Free text |
| Value Domain |
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| Property |
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Person completing record
prsb03-dataelement-12192
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Name
prsb03-dataelement-12193
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|
| Id |
prsb03-dataelement-12193 (2019‑05‑31 16:20:12)
|
| Concept inherits from |
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 |
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Role
prsb03-dataelement-12194
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|
| Id |
prsb03-dataelement-12194 (2019‑05‑31 16:20:12)
|
| Concept inherits from |
prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
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Grade
prsb03-dataelement-12195
|
|
|
| Id |
prsb03-dataelement-12195 (2019‑05‑31 16:20:12)
|
| Concept inherits from |
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 |
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| Property |
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Specialty
prsb03-dataelement-12196
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Organisation
prsb03-dataelement-12197
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Professional identifier
prsb03-dataelement-12198
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|
| Id |
prsb03-dataelement-12198 (2019‑05‑31 16:20:12)
|
| Concept inherits from |
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.
|
| 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 |
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| Property |
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Date completed
prsb03-dataelement-12199
|
|
|
| Id |
prsb03-dataelement-12199 (2019‑05‑31 16:20:12)
|
| Concept inherits from |
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 |
|
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|
Contact details
prsb03-dataelement-12200
|
|
|
| Id |
prsb03-dataelement-12200 (2019‑05‑31 16:20:12)
|
| Concept inherits from |
prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
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|
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 |
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Reported
prsb03-dataelement-10825
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|
| Id |
prsb03-dataelement-10825 (2019‑03‑21 13:40:11)
|
| Description |
Details of the vaccination reported to the professional |
| Relationship |
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Date
prsb03-dataelement-10837
|
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|
| 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 |
|
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Reported
prsb03-dataelement-13849
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|
| 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 |
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| Property |
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Report origin
prsb03-dataelement-13232
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|
| 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 |
|
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Manufacturer
prsb03-dataelement-10689
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Appliances
prsb03-dataelement-13762
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Appliance records entry
prsb03-dataelement-13763
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Appliance name
prsb03-dataelement-13764
|
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|
| 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 |
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|
Product order number
prsb03-dataelement-13765
|
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Manufacturer
prsb03-dataelement-13766
|
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|
| Id |
prsb03-dataelement-13766 (2020‑09‑30 13:01:00)
|
| Description |
Name of appliance manufacturer |
| Operationalization |
Free text |
| Value Domain |
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Batch number
prsb03-dataelement-13767
|
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|
| Id |
prsb03-dataelement-13767 (2020‑09‑30 13:03:53)
|
| Description |
The batch number of the appliance. |
| Operationalization |
Free text |
| Value Domain |
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Size
prsb03-dataelement-13768
|
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| Id |
prsb03-dataelement-13768 (2020‑09‑30 13:07:19)
|
| Description |
The size of the appliance. |
| Operationalization |
UCUM |
| Value Domain |
|
|
|
Weight
prsb03-dataelement-13769
|
|
|
| Id |
prsb03-dataelement-13769 (2020‑09‑30 13:09:16)
|
| Description |
The weight of the appliance. |
| Operationalization |
UCUM |
| Value Domain |
|
|
|
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 |
|
|
|
Route
prsb03-dataelement-13771
|
|
|
|
|
Coded Value
prsb03-dataelement-14268
|
|
|
|
|
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 |
|
|
|
Coded value
prsb03-dataelement-13795
|
|
|
|
|
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 |
|
|
|
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. |
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Presenting complaints or issues
prsb03-dataelement-210
|
|
|
|
|
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.
|
|
|
| Operationalization |
Only ONE (chief complaint) sent as per the ECDS Emergency Care Chief Complaint code
set (SNOMED CT).
|
| Value Domain |
|
|
|
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.
|
|
|
| Relationship |
|
|
|
Coded value
prsb03-dataelement-13785
|
|
|
|
|
Free text
prsb03-dataelement-13786
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
Acuity assessment
prsb03-dataelement-10907
|
|
|
|
|
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. |
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Problem list in dataset prsb03-dataelement-12617
|
|
|
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.
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Date in dataset prsb03-dataelement-12619
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Performing professional
prsb03-dataelement-12133
|
|
|
| Id |
prsb03-dataelement-12133 (2019‑05‑31 16:03:47)
|
| Description |
The professional who identified the problem. |
| Relationship |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Name
prsb03-dataelement-12134
|
|
|
| Id |
prsb03-dataelement-12134 (2019‑05‑31 16:04:17)
|
| Concept inherits from |
prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Name in dataset prsb03-dataelement-12622
|
|
|
Role
prsb03-dataelement-12135
|
|
|
| Id |
prsb03-dataelement-12135 (2019‑05‑31 16:04:17)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Role in dataset prsb03-dataelement-12623
|
|
|
Grade
prsb03-dataelement-12136
|
|
|
| Id |
prsb03-dataelement-12136 (2019‑05‑31 16:04:17)
|
| Concept inherits from |
prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Grade in dataset prsb03-dataelement-12624
|
|
|
Speciality
prsb03-dataelement-12137
|
|
|
| Id |
prsb03-dataelement-12137 (2019‑05‑31 16:04:17)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-12625
|
|
|
Professional identifier
prsb03-dataelement-12138
|
|
|
| Id |
prsb03-dataelement-12138 (2019‑05‑31 16:04:17)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Organisation
prsb03-dataelement-12139
|
|
|
| Id |
prsb03-dataelement-12139 (2019‑05‑31 16:04:17)
|
| Concept inherits from |
prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
|
| Description |
The name of the organisation the professional works for. |
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-12627
|
|
|
Contact details
prsb03-dataelement-12140
|
|
|
| Id |
prsb03-dataelement-12140 (2019‑05‑31 16:04:17)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-12628
|
|
|
Location
prsb03-dataelement-10931
|
|
|
| Id |
prsb03-dataelement-10931 (2019‑04‑30 17:07:45)
|
| Description |
The location the problem was identified. |
| Relationship |
|
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
This concept is inherited by concept
Location in dataset prsb03-dataelement-12629
This concept is inherited by concept
Location in dataset prsb03-dataelement-13246
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 4 times |
| |
This concept is inherited by concept
Coded value in dataset prsb03-dataelement-13460
This concept is inherited by concept
Coded value in dataset prsb03-dataelement-13247
This concept is inherited by concept
Coded value in dataset prsb03-dataelement-13310
This concept is inherited by concept
Coded value in dataset prsb03-dataelement-13272
|
|
|
Free text
prsb03-dataelement-13243
|
|
|
| Id |
prsb03-dataelement-13243 (2020‑07‑27 18:31:13)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited 4 times |
| |
This concept is inherited by concept
Free text in dataset prsb03-dataelement-13461
This concept is inherited by concept
Free text in dataset prsb03-dataelement-13248
This concept is inherited by concept
Free text in dataset prsb03-dataelement-13311
This concept is inherited by concept
Free text in dataset prsb03-dataelement-13273
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
This concept is inherited by concept
Problem in dataset prsb03-dataelement-12630
This concept is inherited by concept
Problem in dataset prsb03-dataelement-12645
|
|
|
Coded value
prsb03-dataelement-13244
|
|
|
|
|
Free text
prsb03-dataelement-13245
|
|
|
| Id |
prsb03-dataelement-13245 (2020‑07‑27 18:46:30)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Free text in dataset prsb03-dataelement-14264
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Onset date in dataset prsb03-dataelement-12631
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
End Date in dataset prsb03-dataelement-12632
|
|
|
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 |
|
|
|
Coded value
prsb03-dataelement-14263
|
|
|
|
|
Free text
prsb03-dataelement-14264
|
|
|
|
|
Problem on discharge
prsb03-dataelement-14261
|
|
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Stage of disease in dataset prsb03-dataelement-12633
|
|
|
Person completing record
prsb03-dataelement-12141
|
|
|
| Id |
prsb03-dataelement-12141 (2019‑05‑31 16:04:31)
|
| Concept inherits from |
prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
|
| Description |
Details of the person completing the record. |
| Relationship |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Name
prsb03-dataelement-12142
|
|
|
| Id |
prsb03-dataelement-12142 (2019‑05‑31 16:04:53)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Name in dataset prsb03-dataelement-12635
|
|
|
Role
prsb03-dataelement-12143
|
|
|
| Id |
prsb03-dataelement-12143 (2019‑05‑31 16:04:53)
|
| Concept inherits from |
prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Role in dataset prsb03-dataelement-12636
|
|
|
Grade
prsb03-dataelement-12144
|
|
|
| Id |
prsb03-dataelement-12144 (2019‑05‑31 16:04:53)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Grade in dataset prsb03-dataelement-12637
|
|
|
Specialty
prsb03-dataelement-12145
|
|
|
| Id |
prsb03-dataelement-12145 (2019‑05‑31 16:04:53)
|
| Concept inherits from |
prsb03-dataelement-11293 (2019‑05‑30 12:25:39)
|
| Description |
The main specialty of the person completing the record. |
| FHIR |
PractitionerRole.specialty |
|
| Relationship |
|
| Rationale |
PractitionerRole.speciality |
| Operationalization |
NHS data dictionary :-
Activity treatment function code
|
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-12638
|
|
|
Organisation
prsb03-dataelement-12146
|
|
|
| Id |
prsb03-dataelement-12146 (2019‑05‑31 16:04:53)
|
| Concept inherits from |
prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
|
| Description |
The organisation the person completing the record works for. |
| Relationship |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-12639
|
|
|
Professional identifier
prsb03-dataelement-12147
|
|
|
| Id |
prsb03-dataelement-12147 (2019‑05‑31 16:04:53)
|
| Concept inherits from |
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.
|
| 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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Date completed
prsb03-dataelement-12148
|
|
|
| Id |
prsb03-dataelement-12148 (2019‑05‑31 16:04:53)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-12641
|
|
|
Contact details
prsb03-dataelement-12149
|
|
|
| Id |
prsb03-dataelement-12149 (2019‑05‑31 16:04:53)
|
| Concept inherits from |
prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-12642
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Comment in dataset prsb03-dataelement-12644
|
|
|
Problems and issues
prsb03-dataelement-211
|
|
|
|
|
Problems and Issues record entry
prsb03-dataelement-10719
|
|
|
|
|
Date Recorded
prsb03-dataelement-10111
|
|
|
|
|
Performing Professional
prsb03-dataelement-10112
|
|
|
| Id |
prsb03-dataelement-10112 (2018‑10‑31)
|
| Description |
Details of the professional recording (including name and role) |
| Value Domain |
|
|
|
Location
prsb03-dataelement-10113
|
|
|
|
|
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 |
|
|
|
Onset date
prsb03-dataelement-10115
|
|
|
|
|
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 |
|
|
|
Stage of Disease
prsb03-dataelement-10117
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Diagnoses
prsb03-dataelement-221
|
|
|
|
|
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.
|
|
|
Date diagnosis made
prsb03-dataelement-10125
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
Diagnosis
prsb03-dataelement-10121
|
|
|
| Id |
prsb03-dataelement-10121 (2018‑10‑31)
|
| Description |
Confirmed diagnosis (or symptom); active diagnosis being treated. |
| 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 |
|
|
|
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.
|
| 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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Person completing record
prsb03-dataelement-10953
|
|
|
| Id |
prsb03-dataelement-10953 (2019‑05‑18 21:06:01)
|
| Concept inherits from |
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 |
|
|
|
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 |
|
|
|
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)
|
|
|
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.
|
|
|
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 |
|
|
|
Location
prsb03-dataelement-13246
|
|
|
|
|
Coded value
prsb03-dataelement-13247
|
|
|
|
|
Free text
prsb03-dataelement-13248
|
|
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Location in dataset prsb03-dataelement-13458
|
|
|
Performing professional
prsb03-dataelement-12150
|
|
|
| Id |
prsb03-dataelement-12150 (2019‑05‑31 16:08:40)
|
| Description |
The professional who performed the procedure. |
| Relationship |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Name
prsb03-dataelement-12151
|
|
|
| Id |
prsb03-dataelement-12151 (2019‑05‑31 16:09:20)
|
| Concept inherits from |
prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Name in dataset prsb03-dataelement-12977
|
|
|
Role
prsb03-dataelement-12152
|
|
|
| Id |
prsb03-dataelement-12152 (2019‑05‑31 16:09:20)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Role in dataset prsb03-dataelement-12978
|
|
|
Grade
prsb03-dataelement-12153
|
|
|
| Id |
prsb03-dataelement-12153 (2019‑05‑31 16:09:20)
|
| Concept inherits from |
prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Grade in dataset prsb03-dataelement-12979
|
|
|
Speciality
prsb03-dataelement-12154
|
|
|
| Id |
prsb03-dataelement-12154 (2019‑05‑31 16:09:20)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-12980
|
|
|
Professional identifier
prsb03-dataelement-12155
|
|
|
| Id |
prsb03-dataelement-12155 (2019‑05‑31 16:09:20)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Organisation
prsb03-dataelement-12156
|
|
|
| Id |
prsb03-dataelement-12156 (2019‑05‑31 16:09:20)
|
| Concept inherits from |
prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
|
| Description |
The name of the organisation the professional works for. |
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-12982
|
|
|
Contact details
prsb03-dataelement-12157
|
|
|
| Id |
prsb03-dataelement-12157 (2019‑05‑31 16:09:20)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-12983
|
|
|
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 |
|
|
|
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.
|
|
|
|
|
Coded value
prsb03-dataelement-13249
|
|
|
|
|
Free text
prsb03-dataelement-13250
|
|
|
|
|
Anatomical site
prsb03-dataelement-10142
|
|
|
|
|
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 |
|
|
|
Free text
prsb03-dataelement-13252
|
|
|
|
|
Laterality
prsb03-dataelement-10143
|
|
|
| Id |
prsb03-dataelement-10143 (2018‑10‑31)
|
| Description |
Laterality of the procedure |
| FHIR |
??Procedure.Code as an EXPRESSION Procedure.bodySite |
|
|
|
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 |
|
|
|
Free text
prsb03-dataelement-13254
|
|
|
|
|
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.
|
| FHIR |
Procedure.complication Procedure.complicationDetail |
|
|
|
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 |
|
|
|
Free text
prsb03-dataelement-13256
|
|
|
|
|
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.
|
| FHIR |
Procedure. Procedure.AnestheticIssues |
|
|
|
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 |
|
|
|
Free text
prsb03-dataelement-13258
|
|
|
|
|
Person completing record
prsb03-dataelement-12158
|
|
|
|
|
Name
prsb03-dataelement-12159
|
|
|
| Id |
prsb03-dataelement-12159 (2019‑05‑31 16:10:02)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-12160
|
|
|
| Id |
prsb03-dataelement-12160 (2019‑05‑31 16:10:02)
|
| Concept inherits from |
prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-12161
|
|
|
| Id |
prsb03-dataelement-12161 (2019‑05‑31 16:10:02)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-12162
|
|
|
|
|
Organisation
prsb03-dataelement-12163
|
|
|
|
|
Professional identifier
prsb03-dataelement-12164
|
|
|
| Id |
prsb03-dataelement-12164 (2019‑05‑31 16:10:02)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-12165
|
|
|
| Id |
prsb03-dataelement-12165 (2019‑05‑31 16:10:02)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-12166
|
|
|
| Id |
prsb03-dataelement-12166 (2019‑05‑31 16:10:02)
|
| Concept inherits from |
prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
|
|
|
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.
|
|
|
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
History
prsb03-dataelement-226
|
|
|
|
|
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.
|
|
|
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 |
|
|
|
Free text
prsb03-dataelement-14266
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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.
|
|
|
Coded value
prsb03-dataelement-13787
|
|
|
|
|
Free text
prsb03-dataelement-13788
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Clinical Summary
prsb03-dataelement-247
|
|
|
|
|
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 |
|
|
|
Location
prsb03-dataelement-13309
|
|
|
| Id |
prsb03-dataelement-13309 (2020‑08‑06 13:56:22)
|
| Description |
The location the clinical summary was written. |
| Relationship |
|
|
|
Coded value
prsb03-dataelement-13310
|
|
|
|
|
Free text
prsb03-dataelement-13311
|
|
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Clinical summary in dataset prsb03-dataelement-10750
|
|
|
Performing professional
prsb03-dataelement-13312
|
|
|
| Id |
prsb03-dataelement-13312 (2020‑08‑06 13:57:51)
|
| Description |
The professional who wrote the clinical summary |
| Relationship |
|
|
|
Name
prsb03-dataelement-13313
|
|
|
| Id |
prsb03-dataelement-13313 (2020‑08‑06 13:58:21)
|
| Concept inherits from |
prsb03-dataelement-11505 (2019‑05‑30 14:35:29)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
|
|
Role
prsb03-dataelement-13314
|
|
|
| Id |
prsb03-dataelement-13314 (2020‑08‑06 13:58:21)
|
| Concept inherits from |
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 |
|
|
|
Grade
prsb03-dataelement-13315
|
|
|
| Id |
prsb03-dataelement-13315 (2020‑08‑06 13:58:21)
|
| Concept inherits from |
prsb03-dataelement-11507 (2019‑05‑30 14:35:29)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Speciality
prsb03-dataelement-13316
|
|
|
|
|
Professional identifier
prsb03-dataelement-13317
|
|
|
| Id |
prsb03-dataelement-13317 (2020‑08‑06 13:58:21)
|
| Concept inherits from |
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 |
|
|
|
Organisation
prsb03-dataelement-13318
|
|
|
|
|
Contact details
prsb03-dataelement-13319
|
|
|
| Id |
prsb03-dataelement-13319 (2020‑08‑06 13:58:21)
|
| Concept inherits from |
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 |
|
|
|
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 |
|
|
|
Name
prsb03-dataelement-13321
|
|
|
| Id |
prsb03-dataelement-13321 (2020‑08‑06 13:59:45)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-13322
|
|
|
| Id |
prsb03-dataelement-13322 (2020‑08‑06 13:59:45)
|
| Concept inherits from |
prsb03-dataelement-13037 (2020‑04‑28 19:33:40)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-13323
|
|
|
| Id |
prsb03-dataelement-13323 (2020‑08‑06 13:59:45)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-13324
|
|
|
|
|
Organisation
prsb03-dataelement-13325
|
|
|
|
|
Professional identifier
prsb03-dataelement-13326
|
|
|
| Id |
prsb03-dataelement-13326 (2020‑08‑06 13:59:45)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-13327
|
|
|
| Id |
prsb03-dataelement-13327 (2020‑08‑06 13:59:45)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-13328
|
|
|
| Id |
prsb03-dataelement-13328 (2020‑08‑06 13:59:45)
|
| Concept inherits from |
prsb03-dataelement-13043 (2020‑04‑28 19:33:40)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 3 times |
| |
This concept is inherited by concept
Formulation in dataset prsb03-dataelement-10749
This concept is inherited by concept
Formulation in dataset prsb03-dataelement-11668
This concept is inherited by concept
Formulation in dataset prsb03-dataelement-10793
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
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 |
|
|
|
Treatments and interventions
prsb03-dataelement-12480
|
|
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Coded value in dataset prsb03-dataelement-13993
|
|
|
Free text
prsb03-dataelement-13260
|
|
|
| Id |
prsb03-dataelement-13260 (2020‑07‑28 11:52:30)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Free text in dataset prsb03-dataelement-13994
|
|
|
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.
|
|
|
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 |
|
|
|
Household composition
prsb03-dataelement-10036
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
Location
prsb03-dataelement-13271
|
|
|
| Id |
prsb03-dataelement-13271 (2020‑07‑28 14:07:57)
|
| Description |
The location where the household composition was taken. |
| Relationship |
|
|
|
Coded value
prsb03-dataelement-13272
|
|
|
|
|
Free text
prsb03-dataelement-13273
|
|
|
|
|
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.
|
|
|
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 |
|
|
|
Free text
prsb03-dataelement-13263
|
|
|
|
|
Performing professional
prsb03-dataelement-11648
|
|
|
| Id |
prsb03-dataelement-11648 (2019‑05‑30 18:03:53)
|
| Description |
The professional who took the household composition. |
| Relationship |
|
|
|
Name
prsb03-dataelement-11649
|
|
|
| Id |
prsb03-dataelement-11649 (2019‑05‑30 18:07:33)
|
| Concept inherits from |
prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
|
|
Role
prsb03-dataelement-11650
|
|
|
| Id |
prsb03-dataelement-11650 (2019‑05‑30 18:07:33)
|
| Concept inherits from |
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 |
|
|
|
Grade
prsb03-dataelement-11651
|
|
|
| Id |
prsb03-dataelement-11651 (2019‑05‑30 18:07:33)
|
| Concept inherits from |
prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Speciality
prsb03-dataelement-11652
|
|
|
|
|
Professional identifier
prsb03-dataelement-11653
|
|
|
| Id |
prsb03-dataelement-11653 (2019‑05‑30 18:07:33)
|
| Concept inherits from |
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 |
|
|
|
Organisation
prsb03-dataelement-11654
|
|
|
|
|
Contact details
prsb03-dataelement-11655
|
|
|
| Id |
prsb03-dataelement-11655 (2019‑05‑30 18:07:33)
|
| Concept inherits from |
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 |
|
|
|
Person completing record
prsb03-dataelement-11521
|
|
|
|
|
Name
prsb03-dataelement-11522
|
|
|
| Id |
prsb03-dataelement-11522 (2019‑05‑30 14:50:56)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-11523
|
|
|
| Id |
prsb03-dataelement-11523 (2019‑05‑30 14:50:56)
|
| Concept inherits from |
prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-11524
|
|
|
| Id |
prsb03-dataelement-11524 (2019‑05‑30 14:50:56)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-11525
|
|
|
|
|
Organisation
prsb03-dataelement-11526
|
|
|
|
|
Professional identifier
prsb03-dataelement-11527
|
|
|
| Id |
prsb03-dataelement-11527 (2019‑05‑30 14:50:56)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-11528
|
|
|
| Id |
prsb03-dataelement-11528 (2019‑05‑30 14:50:56)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-11529
|
|
|
| Id |
prsb03-dataelement-11529 (2019‑05‑30 14:50:56)
|
| Concept inherits from |
prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
Occupational history
prsb03-dataelement-10037
|
|
|
| Id |
prsb03-dataelement-10037 (2018‑10‑31)
|
| Description |
The current and/or previous occupation(s) of the person. |
| FHIR |
Observation.category Observation.code Observation.valueCodeabelConcept Observation.subject |
|
|
|
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 |
|
|
|
Location
prsb03-dataelement-11773
|
|
|
| Id |
prsb03-dataelement-11773 (2019‑05‑31 14:15:38)
|
| Description |
The location where the occupational history was taken. |
| Relationship |
|
|
|
Coded value
prsb03-dataelement-13274
|
|
|
|
|
Free text
prsb03-dataelement-13275
|
|
|
|
|
Occupational history
prsb03-dataelement-13264
|
|
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Coded value in dataset prsb03-dataelement-13280
|
|
|
Free text
prsb03-dataelement-13266
|
|
|
|
|
Performing professional
prsb03-dataelement-11656
|
|
|
| Id |
prsb03-dataelement-11656 (2019‑05‑30 18:08:03)
|
| Description |
The professional who took the occupational history. |
| Relationship |
|
|
|
Name
prsb03-dataelement-11657
|
|
|
| Id |
prsb03-dataelement-11657 (2019‑05‑30 18:08:20)
|
| Concept inherits from |
prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
|
|
Role
prsb03-dataelement-11658
|
|
|
| Id |
prsb03-dataelement-11658 (2019‑05‑30 18:08:20)
|
| Concept inherits from |
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 |
|
|
|
Grade
prsb03-dataelement-11659
|
|
|
| Id |
prsb03-dataelement-11659 (2019‑05‑30 18:08:20)
|
| Concept inherits from |
prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Speciality
prsb03-dataelement-11660
|
|
|
|
|
Professional identifier
prsb03-dataelement-11661
|
|
|
| Id |
prsb03-dataelement-11661 (2019‑05‑30 18:08:20)
|
| Concept inherits from |
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 |
|
|
|
Organisation
prsb03-dataelement-11662
|
|
|
|
|
Contact details
prsb03-dataelement-11663
|
|
|
| Id |
prsb03-dataelement-11663 (2019‑05‑30 18:08:20)
|
| Concept inherits from |
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 |
|
|
|
Person completing record
prsb03-dataelement-11530
|
|
|
|
|
Name
prsb03-dataelement-11531
|
|
|
| Id |
prsb03-dataelement-11531 (2019‑05‑30 14:52:22)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-11532
|
|
|
| Id |
prsb03-dataelement-11532 (2019‑05‑30 14:52:22)
|
| Concept inherits from |
prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-11533
|
|
|
| Id |
prsb03-dataelement-11533 (2019‑05‑30 14:52:22)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-11534
|
|
|
|
|
Organisation
prsb03-dataelement-11535
|
|
|
|
|
Professional identifier
prsb03-dataelement-11536
|
|
|
| Id |
prsb03-dataelement-11536 (2019‑05‑30 14:52:22)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-11537
|
|
|
| Id |
prsb03-dataelement-11537 (2019‑05‑30 14:52:22)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-11538
|
|
|
| Id |
prsb03-dataelement-11538 (2019‑05‑30 14:52:22)
|
| Concept inherits from |
prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
Educational history
prsb03-dataelement-10038
|
|
|
|
|
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 |
|
|
|
Location
prsb03-dataelement-11775
|
|
|
| Id |
prsb03-dataelement-11775 (2019‑05‑31 14:16:57)
|
| Description |
The location where the education history was taken. |
| Relationship |
|
|
|
Coded value
prsb03-dataelement-13276
|
|
|
|
|
Free text
prsb03-dataelement-13277
|
|
|
|
|
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 |
|
|
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 |
|
|
|
Performing professional
prsb03-dataelement-11776
|
|
|
| Id |
prsb03-dataelement-11776 (2019‑05‑31 14:17:28)
|
| Description |
The professional who took the educational history. |
| Relationship |
|
|
|
Name
prsb03-dataelement-11777
|
|
|
| Id |
prsb03-dataelement-11777 (2019‑05‑31 14:17:50)
|
| Concept inherits from |
prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
|
|
Role
prsb03-dataelement-11778
|
|
|
| Id |
prsb03-dataelement-11778 (2019‑05‑31 14:17:50)
|
| Concept inherits from |
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 |
|
|
|
Grade
prsb03-dataelement-11779
|
|
|
| Id |
prsb03-dataelement-11779 (2019‑05‑31 14:17:50)
|
| Concept inherits from |
prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Speciality
prsb03-dataelement-11780
|
|
|
|
|
Professional identifier
prsb03-dataelement-11781
|
|
|
| Id |
prsb03-dataelement-11781 (2019‑05‑31 14:17:50)
|
| Concept inherits from |
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 |
|
|
|
Organisation
prsb03-dataelement-11782
|
|
|
|
|
Contact details
prsb03-dataelement-11783
|
|
|
| Id |
prsb03-dataelement-11783 (2019‑05‑31 14:17:50)
|
| Concept inherits from |
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 |
|
|
|
Person completing record
prsb03-dataelement-11539
|
|
|
|
|
Name
prsb03-dataelement-11540
|
|
|
| Id |
prsb03-dataelement-11540 (2019‑05‑30 14:53:14)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-11541
|
|
|
| Id |
prsb03-dataelement-11541 (2019‑05‑30 14:53:14)
|
| Concept inherits from |
prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-11542
|
|
|
| Id |
prsb03-dataelement-11542 (2019‑05‑30 14:53:14)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-11543
|
|
|
|
|
Organisation
prsb03-dataelement-11544
|
|
|
|
|
Professional identifier
prsb03-dataelement-11545
|
|
|
| Id |
prsb03-dataelement-11545 (2019‑05‑30 14:53:14)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-11546
|
|
|
| Id |
prsb03-dataelement-11546 (2019‑05‑30 14:53:14)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-11547
|
|
|
| Id |
prsb03-dataelement-11547 (2019‑05‑30 14:53:14)
|
| Concept inherits from |
prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
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
|
|
|
|
|
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 |
|
|
|
Location
prsb03-dataelement-11785
|
|
|
| Id |
prsb03-dataelement-11785 (2019‑05‑31 14:18:40)
|
| Description |
The location where the lifestyle choices were taken. |
| Relationship |
|
|
|
Coded value
prsb03-dataelement-13278
|
|
|
|
|
Free text
prsb03-dataelement-13279
|
|
|
|
|
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 |
|
|
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 |
|
|
|
Free text
prsb03-dataelement-13270
|
|
|
|
|
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 |
|
|
|
Performing professional
prsb03-dataelement-11786
|
|
|
| Id |
prsb03-dataelement-11786 (2019‑05‑31 14:19:14)
|
| Description |
The professional who took the lifestyle choices. |
| Relationship |
|
|
|
Name
prsb03-dataelement-11787
|
|
|
| Id |
prsb03-dataelement-11787 (2019‑05‑31 14:19:39)
|
| Concept inherits from |
prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
|
|
Role
prsb03-dataelement-11788
|
|
|
| Id |
prsb03-dataelement-11788 (2019‑05‑31 14:19:39)
|
| Concept inherits from |
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 |
|
|
|
Grade
prsb03-dataelement-11789
|
|
|
| Id |
prsb03-dataelement-11789 (2019‑05‑31 14:19:39)
|
| Concept inherits from |
prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Speciality
prsb03-dataelement-11790
|
|
|
|
|
Professional identifier
prsb03-dataelement-11791
|
|
|
| Id |
prsb03-dataelement-11791 (2019‑05‑31 14:19:39)
|
| Concept inherits from |
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 |
|
|
|
Organisation
prsb03-dataelement-11792
|
|
|
|
|
Contact details
prsb03-dataelement-11793
|
|
|
| Id |
prsb03-dataelement-11793 (2019‑05‑31 14:19:39)
|
| Concept inherits from |
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 |
|
|
|
Person completing record
prsb03-dataelement-11548
|
|
|
|
|
Name
prsb03-dataelement-11549
|
|
|
| Id |
prsb03-dataelement-11549 (2019‑05‑30 14:54:28)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-11550
|
|
|
| Id |
prsb03-dataelement-11550 (2019‑05‑30 14:54:28)
|
| Concept inherits from |
prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-11551
|
|
|
| Id |
prsb03-dataelement-11551 (2019‑05‑30 14:54:28)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-11552
|
|
|
|
|
Organisation
prsb03-dataelement-11553
|
|
|
|
|
Professional identifier
prsb03-dataelement-11554
|
|
|
| Id |
prsb03-dataelement-11554 (2019‑05‑30 14:54:28)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-11555
|
|
|
| Id |
prsb03-dataelement-11555 (2019‑05‑30 14:54:28)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-11556
|
|
|
| Id |
prsb03-dataelement-11556 (2019‑05‑30 14:54:28)
|
| Concept inherits from |
prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
Smoking status
prsb03-dataelement-10040
|
|
|
| Id |
prsb03-dataelement-10040 (2018‑10‑31)
|
| Description |
Details of the person's smoking status. |
| FHIR |
Observation.category Observation.code Observation.valueCodeabelConcept Observation.subject |
|
|
|
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 |
|
|
|
Location
prsb03-dataelement-11795
|
|
|
| Id |
prsb03-dataelement-11795 (2019‑05‑31 14:20:40)
|
| Description |
The location where the smoking status was taken. |
| Relationship |
|
|
|
Coded value
prsb03-dataelement-13281
|
|
|
|
|
Free text
prsb03-dataelement-13282
|
|
|
|
|
Coded value
prsb03-dataelement-13280
|
|
|
|
|
Smoking status
prsb03-dataelement-13283
|
|
|
|
|
Coded value
prsb03-dataelement-13284
|
|
|
|
|
Free text
prsb03-dataelement-13285
|
|
|
|
|
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 |
|
|
|
Smoking record
prsb03-dataelement-13995
|
|
|
|
|
Overall smoking status
prsb03-dataelement-13996
|
|
|
| Id |
prsb03-dataelement-13996 (2021‑02‑11 18:40:44)
|
| Concept inherits from |
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 |
|
|
|
Date of quitting
prsb03-dataelement-13997
|
|
|
| Id |
prsb03-dataelement-13997 (2021‑02‑11 18:40:44)
|
| Concept inherits from |
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 |
|
|
|
Other tobacco products used
prsb03-dataelement-13998
|
|
|
| Id |
prsb03-dataelement-13998 (2021‑02‑11 18:40:44)
|
| Concept inherits from |
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 |
|
|
|
Information and advice given
prsb03-dataelement-13999
|
|
|
| Id |
prsb03-dataelement-13999 (2021‑02‑11 18:40:44)
|
| Concept inherits from |
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.
|
|
|
| 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 |
|
|
|
Nicotine Replacement Therapy used
prsb03-dataelement-14000
|
|
|
| Id |
prsb03-dataelement-14000 (2021‑02‑11 18:40:44)
|
| Concept inherits from |
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 |
|
|
|
Varenicline or other pharmacotherapy used
prsb03-dataelement-14001
|
|
|
| Id |
prsb03-dataelement-14001 (2021‑02‑11 18:40:44)
|
| Concept inherits from |
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 |
|
|
|
e-cigarettes used
prsb03-dataelement-14002
|
|
|
| Id |
prsb03-dataelement-14002 (2021‑02‑11 18:40:44)
|
| Concept inherits from |
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 |
|
|
|
Therapy prescribed (see medication item entry information model)
prsb03-dataelement-14003
|
|
|
| Id |
prsb03-dataelement-14003 (2021‑02‑11 18:40:44)
|
| Concept inherits from |
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 |
|
|
|
Referral details
prsb03-dataelement-14004
|
|
|
| Id |
prsb03-dataelement-14004 (2021‑02‑11 18:40:44)
|
| Concept inherits from |
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 |
|
|
|
Comment
prsb03-dataelement-14005
|
|
|
| Id |
prsb03-dataelement-14005 (2021‑02‑11 18:40:44)
|
| Concept inherits from |
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 |
|
|
|
Set quit date
prsb03-dataelement-14007
|
|
|
| Id |
prsb03-dataelement-14007 (2021‑02‑12 11:20:10)
|
| Concept inherits from |
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 |
|
|
|
Treatments and interventions and changes made to treatments.
prsb03-dataelement-13992
|
|
|
| Id |
prsb03-dataelement-13992 (2021‑02‑11 16:46:41)
|
| Concept inherits from |
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 |
|
|
|
Coded value
prsb03-dataelement-13993
|
|
|
|
|
Free text
prsb03-dataelement-13994
|
|
|
|
|
Date stopped smoking
prsb03-dataelement-13287
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
Performing professional
prsb03-dataelement-11796
|
|
|
| Id |
prsb03-dataelement-11796 (2019‑05‑31 14:21:14)
|
| Description |
The professional who took the smoking status. |
| Relationship |
|
|
|
Name
prsb03-dataelement-11797
|
|
|
| Id |
prsb03-dataelement-11797 (2019‑05‑31 14:21:51)
|
| Concept inherits from |
prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
|
|
Role
prsb03-dataelement-11798
|
|
|
| Id |
prsb03-dataelement-11798 (2019‑05‑31 14:21:51)
|
| Concept inherits from |
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 |
|
|
|
Grade
prsb03-dataelement-11799
|
|
|
| Id |
prsb03-dataelement-11799 (2019‑05‑31 14:21:51)
|
| Concept inherits from |
prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Speciality
prsb03-dataelement-11800
|
|
|
|
|
Professional identifier
prsb03-dataelement-11801
|
|
|
| Id |
prsb03-dataelement-11801 (2019‑05‑31 14:21:51)
|
| Concept inherits from |
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 |
|
|
|
Organisation
prsb03-dataelement-11802
|
|
|
|
|
Contact details
prsb03-dataelement-11803
|
|
|
| Id |
prsb03-dataelement-11803 (2019‑05‑31 14:21:51)
|
| Concept inherits from |
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 |
|
|
|
Person completing record
prsb03-dataelement-11557
|
|
|
|
|
Name
prsb03-dataelement-11558
|
|
|
| Id |
prsb03-dataelement-11558 (2019‑05‑30 14:55:47)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-11559
|
|
|
| Id |
prsb03-dataelement-11559 (2019‑05‑30 14:55:47)
|
| Concept inherits from |
prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-11560
|
|
|
| Id |
prsb03-dataelement-11560 (2019‑05‑30 14:55:47)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-11561
|
|
|
|
|
Organisation
prsb03-dataelement-11562
|
|
|
|
|
Professional identifier
prsb03-dataelement-11563
|
|
|
| Id |
prsb03-dataelement-11563 (2019‑05‑30 14:55:47)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-11564
|
|
|
| Id |
prsb03-dataelement-11564 (2019‑05‑30 14:55:47)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-11565
|
|
|
| Id |
prsb03-dataelement-11565 (2019‑05‑30 14:55:47)
|
| Concept inherits from |
prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
Alcohol intake
prsb03-dataelement-10041
|
|
|
|
|
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 |
|
|
|
Location
prsb03-dataelement-11805
|
|
|
| Id |
prsb03-dataelement-11805 (2019‑05‑31 14:23:38)
|
| Description |
The location where the alcohol intake was noted. |
| Relationship |
|
|
|
Coded value
prsb03-dataelement-13332
|
|
|
|
|
Free text
prsb03-dataelement-13333
|
|
|
|
|
Alcohol intake
prsb03-dataelement-13290
|
|
|
|
|
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 |
|
|
|
Free text
prsb03-dataelement-13292
|
|
|
|
|
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 |
|
|
|
Performing professional
prsb03-dataelement-11806
|
|
|
| Id |
prsb03-dataelement-11806 (2019‑05‑31 14:24:13)
|
| Description |
The professional who noted the alcohol intake. |
| Relationship |
|
|
|
Name
prsb03-dataelement-11807
|
|
|
| Id |
prsb03-dataelement-11807 (2019‑05‑31 14:24:33)
|
| Concept inherits from |
prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
|
|
Role
prsb03-dataelement-11808
|
|
|
| Id |
prsb03-dataelement-11808 (2019‑05‑31 14:24:33)
|
| Concept inherits from |
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 |
|
|
|
Grade
prsb03-dataelement-11809
|
|
|
| Id |
prsb03-dataelement-11809 (2019‑05‑31 14:24:33)
|
| Concept inherits from |
prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Speciality
prsb03-dataelement-11810
|
|
|
|
|
Professional identifier
prsb03-dataelement-11811
|
|
|
| Id |
prsb03-dataelement-11811 (2019‑05‑31 14:24:33)
|
| Concept inherits from |
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 |
|
|
|
Organisation
prsb03-dataelement-11812
|
|
|
|
|
Contact details
prsb03-dataelement-11813
|
|
|
| Id |
prsb03-dataelement-11813 (2019‑05‑31 14:24:33)
|
| Concept inherits from |
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 |
|
|
|
Person completing record
prsb03-dataelement-11566
|
|
|
|
|
Name
prsb03-dataelement-11567
|
|
|
| Id |
prsb03-dataelement-11567 (2019‑05‑30 14:57:06)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-11568
|
|
|
| Id |
prsb03-dataelement-11568 (2019‑05‑30 14:57:06)
|
| Concept inherits from |
prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-11569
|
|
|
| Id |
prsb03-dataelement-11569 (2019‑05‑30 14:57:06)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-11570
|
|
|
|
|
Organisation
prsb03-dataelement-11571
|
|
|
|
|
Professional identifier
prsb03-dataelement-11572
|
|
|
| Id |
prsb03-dataelement-11572 (2019‑05‑30 14:57:06)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-11573
|
|
|
| Id |
prsb03-dataelement-11573 (2019‑05‑30 14:57:06)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-11574
|
|
|
| Id |
prsb03-dataelement-11574 (2019‑05‑30 14:57:06)
|
| Concept inherits from |
prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
Drug/substance use
prsb03-dataelement-10042
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
Coded value
prsb03-dataelement-13334
|
|
|
|
|
Free text
prsb03-dataelement-13335
|
|
|
|
|
Drug/substance use
prsb03-dataelement-13336
|
|
|
|
|
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 |
|
|
|
Free text
prsb03-dataelement-13338
|
|
|
|
|
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 |
|
|
|
Name
prsb03-dataelement-11817
|
|
|
| Id |
prsb03-dataelement-11817 (2019‑05‑31 14:26:11)
|
| Concept inherits from |
prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
|
|
Role
prsb03-dataelement-11818
|
|
|
| Id |
prsb03-dataelement-11818 (2019‑05‑31 14:26:11)
|
| Concept inherits from |
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 |
|
|
|
Grade
prsb03-dataelement-11819
|
|
|
| Id |
prsb03-dataelement-11819 (2019‑05‑31 14:26:11)
|
| Concept inherits from |
prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Speciality
prsb03-dataelement-11820
|
|
|
|
|
Professional identifier
prsb03-dataelement-11821
|
|
|
| Id |
prsb03-dataelement-11821 (2019‑05‑31 14:26:11)
|
| Concept inherits from |
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 |
|
|
|
Organisation
prsb03-dataelement-11822
|
|
|
|
|
Contact details
prsb03-dataelement-11823
|
|
|
| Id |
prsb03-dataelement-11823 (2019‑05‑31 14:26:11)
|
| Concept inherits from |
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 |
|
|
|
Person completing record
prsb03-dataelement-11575
|
|
|
|
|
Name
prsb03-dataelement-11576
|
|
|
| Id |
prsb03-dataelement-11576 (2019‑05‑30 14:57:58)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-11577
|
|
|
| Id |
prsb03-dataelement-11577 (2019‑05‑30 14:57:58)
|
| Concept inherits from |
prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-11578
|
|
|
| Id |
prsb03-dataelement-11578 (2019‑05‑30 14:57:58)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-11579
|
|
|
|
|
Organisation
prsb03-dataelement-11580
|
|
|
|
|
Professional identifier
prsb03-dataelement-11581
|
|
|
| Id |
prsb03-dataelement-11581 (2019‑05‑30 14:57:58)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-11582
|
|
|
| Id |
prsb03-dataelement-11582 (2019‑05‑30 14:57:58)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-11583
|
|
|
| Id |
prsb03-dataelement-11583 (2019‑05‑30 14:57:58)
|
| Concept inherits from |
prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
Social circumstances
prsb03-dataelement-10043
|
|
|
|
|
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 |
|
|
|
Location
prsb03-dataelement-11825
|
|
|
| Id |
prsb03-dataelement-11825 (2019‑05‑31 14:27:00)
|
| Description |
The location where the social circumstances were taken. |
| Relationship |
|
|
|
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 |
|
|
|
Free text
prsb03-dataelement-13340
|
|
|
|
|
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 |
|
|
|
Performing professional
prsb03-dataelement-11826
|
|
|
| Id |
prsb03-dataelement-11826 (2019‑05‑31 14:27:37)
|
| Description |
The professional who took the social circumstances. |
| Relationship |
|
|
|
Name
prsb03-dataelement-11827
|
|
|
| Id |
prsb03-dataelement-11827 (2019‑05‑31 14:27:55)
|
| Concept inherits from |
prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
|
|
Role
prsb03-dataelement-11828
|
|
|
| Id |
prsb03-dataelement-11828 (2019‑05‑31 14:27:55)
|
| Concept inherits from |
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 |
|
|
|
Grade
prsb03-dataelement-11829
|
|
|
| Id |
prsb03-dataelement-11829 (2019‑05‑31 14:27:55)
|
| Concept inherits from |
prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Speciality
prsb03-dataelement-11830
|
|
|
|
|
Professional identifier
prsb03-dataelement-11831
|
|
|
| Id |
prsb03-dataelement-11831 (2019‑05‑31 14:27:55)
|
| Concept inherits from |
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 |
|
|
|
Organisation
prsb03-dataelement-11832
|
|
|
|
|
Contact details
prsb03-dataelement-11833
|
|
|
| Id |
prsb03-dataelement-11833 (2019‑05‑31 14:27:55)
|
| Concept inherits from |
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 |
|
|
|
Person completing record
prsb03-dataelement-11584
|
|
|
|
|
Name
prsb03-dataelement-11585
|
|
|
| Id |
prsb03-dataelement-11585 (2019‑05‑30 14:59:16)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-11586
|
|
|
| Id |
prsb03-dataelement-11586 (2019‑05‑30 14:59:16)
|
| Concept inherits from |
prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-11587
|
|
|
| Id |
prsb03-dataelement-11587 (2019‑05‑30 14:59:16)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-11588
|
|
|
|
|
Organisation
prsb03-dataelement-11589
|
|
|
|
|
Professional identifier
prsb03-dataelement-11590
|
|
|
| Id |
prsb03-dataelement-11590 (2019‑05‑30 14:59:16)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-11591
|
|
|
| Id |
prsb03-dataelement-11591 (2019‑05‑30 14:59:16)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-11592
|
|
|
| Id |
prsb03-dataelement-11592 (2019‑05‑30 14:59:16)
|
| Concept inherits from |
prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
Access
prsb03-dataelement-10045
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
Coded value
prsb03-dataelement-13343
|
|
|
|
|
Free text
prsb03-dataelement-13344
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
Name
prsb03-dataelement-11847
|
|
|
| Id |
prsb03-dataelement-11847 (2019‑05‑31 14:31:19)
|
| Concept inherits from |
prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
|
|
Role
prsb03-dataelement-11848
|
|
|
| Id |
prsb03-dataelement-11848 (2019‑05‑31 14:31:19)
|
| Concept inherits from |
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 |
|
|
|
Grade
prsb03-dataelement-11849
|
|
|
| Id |
prsb03-dataelement-11849 (2019‑05‑31 14:31:19)
|
| Concept inherits from |
prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Speciality
prsb03-dataelement-11850
|
|
|
|
|
Professional identifier
prsb03-dataelement-11851
|
|
|
| Id |
prsb03-dataelement-11851 (2019‑05‑31 14:31:19)
|
| Concept inherits from |
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 |
|
|
|
Organisation
prsb03-dataelement-11852
|
|
|
|
|
Contact details
prsb03-dataelement-11853
|
|
|
| Id |
prsb03-dataelement-11853 (2019‑05‑31 14:31:19)
|
| Concept inherits from |
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 |
|
|
|
Person completing record
prsb03-dataelement-11602
|
|
|
|
|
Name
prsb03-dataelement-11603
|
|
|
| Id |
prsb03-dataelement-11603 (2019‑05‑30 15:01:27)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-11604
|
|
|
| Id |
prsb03-dataelement-11604 (2019‑05‑30 15:01:27)
|
| Concept inherits from |
prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-11605
|
|
|
| Id |
prsb03-dataelement-11605 (2019‑05‑30 15:01:27)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-11606
|
|
|
|
|
Organisation
prsb03-dataelement-11607
|
|
|
|
|
Professional identifier
prsb03-dataelement-11608
|
|
|
| Id |
prsb03-dataelement-11608 (2019‑05‑30 15:01:27)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-11609
|
|
|
| Id |
prsb03-dataelement-11609 (2019‑05‑30 15:01:27)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-11610
|
|
|
| Id |
prsb03-dataelement-11610 (2019‑05‑30 15:01:27)
|
| Concept inherits from |
prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
Dependants
prsb03-dataelement-10046
|
|
|
|
|
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 |
|
|
|
Location
prsb03-dataelement-11855
|
|
|
| Id |
prsb03-dataelement-11855 (2019‑05‑31 14:32:07)
|
| Description |
The location where the dependents details were taken. |
| Relationship |
|
|
|
Coded value
prsb03-dataelement-13346
|
|
|
|
|
Free text
prsb03-dataelement-13347
|
|
|
|
|
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 |
|
|
|
Performing professional
prsb03-dataelement-11856
|
|
|
| Id |
prsb03-dataelement-11856 (2019‑05‑31 14:32:34)
|
| Description |
The professional who took the dependents details. |
| Relationship |
|
|
|
Name
prsb03-dataelement-11857
|
|
|
| Id |
prsb03-dataelement-11857 (2019‑05‑31 14:32:53)
|
| Concept inherits from |
prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
|
|
Role
prsb03-dataelement-11858
|
|
|
| Id |
prsb03-dataelement-11858 (2019‑05‑31 14:32:53)
|
| Concept inherits from |
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 |
|
|
|
Grade
prsb03-dataelement-11859
|
|
|
| Id |
prsb03-dataelement-11859 (2019‑05‑31 14:32:53)
|
| Concept inherits from |
prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Speciality
prsb03-dataelement-11860
|
|
|
|
|
Professional identifier
prsb03-dataelement-11861
|
|
|
| Id |
prsb03-dataelement-11861 (2019‑05‑31 14:32:53)
|
| Concept inherits from |
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 |
|
|
|
Organisation
prsb03-dataelement-11862
|
|
|
|
|
Contact details
prsb03-dataelement-11863
|
|
|
| Id |
prsb03-dataelement-11863 (2019‑05‑31 14:32:53)
|
| Concept inherits from |
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 |
|
|
|
Person completing record
prsb03-dataelement-11611
|
|
|
|
|
Name
prsb03-dataelement-11612
|
|
|
| Id |
prsb03-dataelement-11612 (2019‑05‑30 15:03:59)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-11613
|
|
|
| Id |
prsb03-dataelement-11613 (2019‑05‑30 15:03:59)
|
| Concept inherits from |
prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-11614
|
|
|
| Id |
prsb03-dataelement-11614 (2019‑05‑30 15:03:59)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-11615
|
|
|
|
|
Organisation
prsb03-dataelement-11616
|
|
|
|
|
Professional identifier
prsb03-dataelement-11617
|
|
|
| Id |
prsb03-dataelement-11617 (2019‑05‑30 15:03:59)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-11618
|
|
|
| Id |
prsb03-dataelement-11618 (2019‑05‑30 15:03:59)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-11619
|
|
|
| Id |
prsb03-dataelement-11619 (2019‑05‑30 15:03:59)
|
| Concept inherits from |
prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
Accommodation status
prsb03-dataelement-10047
|
|
|
|
|
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 |
|
|
|
Location
prsb03-dataelement-11865
|
|
|
| Id |
prsb03-dataelement-11865 (2019‑05‑31 14:33:51)
|
| Description |
The location where the accommodation was taken. |
| Relationship |
|
|
|
Coded value
prsb03-dataelement-13352
|
|
|
|
|
Free text
prsb03-dataelement-13353
|
|
|
|
|
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.
|
|
|
Coded value
prsb03-dataelement-13349
|
|
|
|
|
Free text
prsb03-dataelement-13350
|
|
|
|
|
Performing professional
prsb03-dataelement-11866
|
|
|
| Id |
prsb03-dataelement-11866 (2019‑05‑31 14:34:24)
|
| Description |
The professional who took the accommodation status. |
| Relationship |
|
|
|
Name
prsb03-dataelement-11867
|
|
|
| Id |
prsb03-dataelement-11867 (2019‑05‑31 14:34:45)
|
| Concept inherits from |
prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
|
|
Role
prsb03-dataelement-11868
|
|
|
| Id |
prsb03-dataelement-11868 (2019‑05‑31 14:34:45)
|
| Concept inherits from |
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 |
|
|
|
Grade
prsb03-dataelement-11869
|
|
|
| Id |
prsb03-dataelement-11869 (2019‑05‑31 14:34:45)
|
| Concept inherits from |
prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Speciality
prsb03-dataelement-11870
|
|
|
|
|
Professional identifier
prsb03-dataelement-11871
|
|
|
| Id |
prsb03-dataelement-11871 (2019‑05‑31 14:34:45)
|
| Concept inherits from |
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 |
|
|
|
Organisation
prsb03-dataelement-11872
|
|
|
|
|
Contact details
prsb03-dataelement-11873
|
|
|
| Id |
prsb03-dataelement-11873 (2019‑05‑31 14:34:45)
|
| Concept inherits from |
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 |
|
|
|
Person completing record
prsb03-dataelement-11874
|
|
|
|
|
Name
prsb03-dataelement-11875
|
|
|
| Id |
prsb03-dataelement-11875 (2019‑05‑31 14:35:30)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-11876
|
|
|
| Id |
prsb03-dataelement-11876 (2019‑05‑31 14:35:30)
|
| Concept inherits from |
prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-11877
|
|
|
| Id |
prsb03-dataelement-11877 (2019‑05‑31 14:35:30)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-11878
|
|
|
|
|
Organisation
prsb03-dataelement-11879
|
|
|
|
|
Professional identifier
prsb03-dataelement-11880
|
|
|
| Id |
prsb03-dataelement-11880 (2019‑05‑31 14:35:30)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-11881
|
|
|
| Id |
prsb03-dataelement-11881 (2019‑05‑31 14:35:30)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-11882
|
|
|
| Id |
prsb03-dataelement-11882 (2019‑05‑31 14:35:30)
|
| Concept inherits from |
prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
Person completing record
prsb03-dataelement-11620
|
|
|
|
|
Household environment
prsb03-dataelement-10051
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
Coded value
prsb03-dataelement-13351
|
|
|
|
|
Free text
prsb03-dataelement-13354
|
|
|
|
|
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 |
|
|
Coded value
prsb03-dataelement-13356
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
Name
prsb03-dataelement-11886
|
|
|
| Id |
prsb03-dataelement-11886 (2019‑05‑31 14:37:24)
|
| Concept inherits from |
prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
|
|
Role
prsb03-dataelement-11887
|
|
|
| Id |
prsb03-dataelement-11887 (2019‑05‑31 14:37:24)
|
| Concept inherits from |
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 |
|
|
|
Grade
prsb03-dataelement-11888
|
|
|
| Id |
prsb03-dataelement-11888 (2019‑05‑31 14:37:24)
|
| Concept inherits from |
prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Speciality
prsb03-dataelement-11889
|
|
|
|
|
Professional identifier
prsb03-dataelement-11890
|
|
|
| Id |
prsb03-dataelement-11890 (2019‑05‑31 14:37:24)
|
| Concept inherits from |
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 |
|
|
|
Organisation
prsb03-dataelement-11891
|
|
|
|
|
Contact details
prsb03-dataelement-11892
|
|
|
| Id |
prsb03-dataelement-11892 (2019‑05‑31 14:37:24)
|
| Concept inherits from |
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 |
|
|
|
Person completing record
prsb03-dataelement-11621
|
|
|
|
|
Name
prsb03-dataelement-11622
|
|
|
| Id |
prsb03-dataelement-11622 (2019‑05‑30 15:06:41)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-11623
|
|
|
| Id |
prsb03-dataelement-11623 (2019‑05‑30 15:06:41)
|
| Concept inherits from |
prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-11624
|
|
|
| Id |
prsb03-dataelement-11624 (2019‑05‑30 15:06:41)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-11625
|
|
|
|
|
Organisation
prsb03-dataelement-11626
|
|
|
|
|
Professional identifier
prsb03-dataelement-11627
|
|
|
| Id |
prsb03-dataelement-11627 (2019‑05‑30 15:06:41)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-11628
|
|
|
| Id |
prsb03-dataelement-11628 (2019‑05‑30 15:06:41)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-11629
|
|
|
| Id |
prsb03-dataelement-11629 (2019‑05‑30 15:06:41)
|
| Concept inherits from |
prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
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.
|
|
|
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 |
|
|
|
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 |
|
|
|
Family and Household
prsb03-dataelement-10048
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
Asylum Status
prsb03-dataelement-10052
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Personal
prsb03-dataelement-10059
|
|
|
|
|
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 |
|
|
|
Person completing record
prsb03-dataelement-10863
|
|
|
| Id |
prsb03-dataelement-10863 (2019‑03‑27 17:52:28)
|
| Concept inherits from |
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 |
|
|
|
Smoking record
prsb03-dataelement-12489
|
|
|
| Id |
prsb03-dataelement-12489 (2019‑10‑29 14:19:57)
|
| Description |
Details of the person's smoking record |
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Smoking record in dataset prsb03-dataelement-13995
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Set quit date in dataset prsb03-dataelement-14007
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Date of quitting in dataset prsb03-dataelement-13997
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
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.
|
|
|
| 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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
e-cigarettes used in dataset prsb03-dataelement-14002
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Referral details in dataset prsb03-dataelement-14004
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Comment in dataset prsb03-dataelement-14005
|
|
|
Alcohol record
prsb03-dataelement-12498
|
|
|
|
|
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]
|
|
|
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 |
|
|
|
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.
|
|
|
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 |
|
|
|
Typical consumption cluster
prsb03-dataelement-12502
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
if AUDIT-C score >=5
prsb03-dataelement-12507
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Medications and medical devices
prsb03-dataelement-12526
|
|
|
|
|
Medication administration record entry
prsb03-dataelement-12527
|
|
|
|
|
Medication name
prsb03-dataelement-12528
|
|
|
| Id |
prsb03-dataelement-12528 (2019‑11‑04 14:01:34)
|
| Concept inherits from |
prsb03-dataelement-12484 (2019‑07‑03 12:27:06)
|
| Description |
May be generic name or brand name. |
| 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)
|
|
|
|
Route
prsb03-dataelement-12529
|
|
|
|
|
Dose administered
prsb03-dataelement-12530
|
|
|
| Id |
prsb03-dataelement-12530 (2019‑11‑04 14:01:34)
|
| Concept inherits from |
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 |
|
|
|
Administration date and time
prsb03-dataelement-12531
|
|
|
| Id |
prsb03-dataelement-12531 (2019‑11‑04 14:01:34)
|
| Concept inherits from |
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 |
|
|
|
Medication item entry
prsb03-dataelement-12532
|
|
|
| Id |
prsb03-dataelement-12532 (2019‑11‑04 14:01:34)
|
| Concept inherits from |
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.
|
|
|
Medication item cluster
prsb03-dataelement-12533
|
|
|
|
|
Date
prsb03-dataelement-12534
|
|
|
| Id |
prsb03-dataelement-12534 (2019‑11‑04 14:01:34)
|
| Concept inherits from |
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 |
|
|
|
Location
prsb03-dataelement-12535
|
|
|
|
|
Performing professional
prsb03-dataelement-12536
|
|
|
|
|
Performing professional
prsb03-dataelement-12537
|
|
|
|
|
Name
prsb03-dataelement-12538
|
|
|
| Id |
prsb03-dataelement-12538 (2019‑11‑04 14:01:34)
|
| Concept inherits from |
prsb03-dataelement-12003 (2019‑05‑31 15:12:48)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
|
|
Role
prsb03-dataelement-12539
|
|
|
| Id |
prsb03-dataelement-12539 (2019‑11‑04 14:01:34)
|
| Concept inherits from |
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 |
|
|
|
Grade
prsb03-dataelement-12540
|
|
|
| Id |
prsb03-dataelement-12540 (2019‑11‑04 14:01:34)
|
| Concept inherits from |
prsb03-dataelement-12005 (2019‑05‑31 15:12:48)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Speciality
prsb03-dataelement-12541
|
|
|
|
|
Professional identifier
prsb03-dataelement-12542
|
|
|
| Id |
prsb03-dataelement-12542 (2019‑11‑04 14:01:34)
|
| Concept inherits from |
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 |
|
|
|
Organisation
prsb03-dataelement-12543
|
|
|
|
|
Contact details
prsb03-dataelement-12544
|
|
|
| Id |
prsb03-dataelement-12544 (2019‑11‑04 14:01:34)
|
| Concept inherits from |
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 |
|
|
|
Medication name
prsb03-dataelement-12545
|
|
|
| Id |
prsb03-dataelement-12545 (2019‑11‑04 14:01:34)
|
| Concept inherits from |
prsb03-dataelement-10536 (2018‑10‑31)
|
| Description |
May be generic name or brand name. |
| 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)
|
|
|
|
Form
prsb03-dataelement-12546
|
|
|
| Id |
prsb03-dataelement-12546 (2019‑11‑04 14:01:34)
|
| Concept inherits from |
prsb03-dataelement-10537 (2018‑10‑31)
|
| Description |
The form of the medication e.g. capsule, drops, tablet, lotion etc. |
| 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
|
|
|
|
Quantity supplied
prsb03-dataelement-12547
|
|
|
| Id |
prsb03-dataelement-12547 (2019‑11‑04 14:01:34)
|
| Concept inherits from |
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
|
| FHIR |
MedicationStatement.quantityDispensed (Amount of medication to supply per dispense)
quantity (as a valueQuantity) - Mandatory quantityText (as a valueString) - Mandatory
|
|
| Operationalization |
Free text |
|
|
Route
prsb03-dataelement-12548
|
|
|
|
|
Site
prsb03-dataelement-12549
|
|
|
|
|
Method
prsb03-dataelement-12550
|
|
|
|
|
Dose directions description
prsb03-dataelement-12551
|
|
|
| Id |
prsb03-dataelement-12551 (2019‑11‑04 14:01:34)
|
| Concept inherits from |
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”.
|
| FHIR |
MedicationStatement.dosage.text |
|
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Dose amount description
prsb03-dataelement-12552
|
|
|
| Id |
prsb03-dataelement-12552 (2019‑11‑04 14:01:34)
|
| Concept inherits from |
prsb03-dataelement-10542 (2018‑10‑31)
|
| Description |
A description of the medication single dose amount e.g. "30 mg" or "2 tabs". |
| FHIR |
MedicationStatement.dosage.text |
|
| Operationalization |
Free text |
| Value Domain |
|
|
|
Dose timing description
prsb03-dataelement-12553
|
|
|
| Id |
prsb03-dataelement-12553 (2019‑11‑04 14:01:34)
|
| Concept inherits from |
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".
|
| FHIR |
MedicationStatement.dosage.timing [a complex data type that holds lots of timing formats] |
|
| Operationalization |
Free text |
| Value Domain |
|
|
|
Parsable dose directions
prsb03-dataelement-12554
|
|
|
| Id |
prsb03-dataelement-12554 (2019‑11‑04 14:01:34)
|
| Concept inherits from |
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 |
|
|
|
Structured dose direction cluster
prsb03-dataelement-12555
|
|
|
| Id |
prsb03-dataelement-12555 (2019‑11‑04 14:01:34)
|
| Concept inherits from |
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.
|
|
|
Structured dose direction
prsb03-dataelement-12556
|
|
|
|
|
Structured dose amount
prsb03-dataelement-12557
|
|
|
|
|
Structured dose timing
prsb03-dataelement-12558
|
|
|
|
|
Dose direction duration
prsb03-dataelement-12559
|
|
|
| Id |
prsb03-dataelement-12559 (2019‑11‑04 14:01:34)
|
| Concept inherits from |
prsb03-dataelement-10548 (2018‑10‑31)
|
| Description |
Recommendation of the time period for which the medication should be continued, including
direction not to discontinue.
|
| 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 |
|
|
|
Additional instructions
prsb03-dataelement-12560
|
|
|
| Id |
prsb03-dataelement-12560 (2019‑11‑04 14:01:34)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Request for advice
prsb03-dataelement-12561
|
|
|
|
|
Person completing record
prsb03-dataelement-12562
|
|
|
| Id |
prsb03-dataelement-12562 (2019‑11‑04 14:01:34)
|
| Concept inherits from |
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 |
|
|
|
Course details cluster
prsb03-dataelement-12563
|
|
|
|
|
Course status
prsb03-dataelement-12564
|
|
|
|
|
Indication
prsb03-dataelement-12565
|
|
|
| Id |
prsb03-dataelement-12565 (2019‑11‑04 14:01:34)
|
| Concept inherits from |
prsb03-dataelement-10546 (2018‑10‑31)
|
| Description |
Reason for medication being prescribed, where known. |
| FHIR |
MedicationStatement.reasonCode |
|
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Start date/time
prsb03-dataelement-12566
|
|
|
| Id |
prsb03-dataelement-12566 (2019‑11‑04 14:01:34)
|
| Concept inherits from |
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 |
|
|
|
End date/time
prsb03-dataelement-12567
|
|
|
| Id |
prsb03-dataelement-12567 (2019‑11‑04 14:01:34)
|
| Concept inherits from |
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 |
|
|
|
Link to indication record
prsb03-dataelement-12568
|
|
|
| Id |
prsb03-dataelement-12568 (2019‑11‑04 14:01:34)
|
| Concept inherits from |
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 |
|
|
|
Comment/recommendation
prsb03-dataelement-12569
|
|
|
| Id |
prsb03-dataelement-12569 (2019‑11‑04 14:01:34)
|
| Concept inherits from |
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
|
| FHIR |
[JH] This will be dropped from the PRSB information model, as conflicts with description
above
|
|
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Medication change summary cluster
prsb03-dataelement-12570
|
|
|
|
|
Status
prsb03-dataelement-12571
|
|
|
|
|
Indication
prsb03-dataelement-12572
|
|
|
| Id |
prsb03-dataelement-12572 (2019‑11‑04 14:01:34)
|
| Concept inherits from |
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 |
|
|
|
Date of change
prsb03-dataelement-12573
|
|
|
| Id |
prsb03-dataelement-12573 (2019‑11‑04 14:01:34)
|
| Concept inherits from |
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 |
|
|
|
Description of amendment
prsb03-dataelement-12574
|
|
|
| Id |
prsb03-dataelement-12574 (2019‑11‑04 14:01:34)
|
| Concept inherits from |
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 |
|
|
|
Total dose daily quantity
prsb03-dataelement-12575
|
|
|
| Id |
prsb03-dataelement-12575 (2019‑11‑04 14:01:34)
|
| Concept inherits from |
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 |
|
|
|
Person completing record
prsb03-dataelement-12576
|
|
|
|
|
Name
prsb03-dataelement-12577
|
|
|
| Id |
prsb03-dataelement-12577 (2019‑11‑04 14:01:34)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-12578
|
|
|
| Id |
prsb03-dataelement-12578 (2019‑11‑04 14:01:34)
|
| Concept inherits from |
prsb03-dataelement-11995 (2019‑05‑31 15:12:02)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-12579
|
|
|
| Id |
prsb03-dataelement-12579 (2019‑11‑04 14:01:34)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-12580
|
|
|
|
|
Organisation
prsb03-dataelement-12581
|
|
|
|
|
Professional identifier
prsb03-dataelement-12582
|
|
|
| Id |
prsb03-dataelement-12582 (2019‑11‑04 14:01:34)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-12583
|
|
|
| Id |
prsb03-dataelement-12583 (2019‑11‑04 14:01:34)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-12584
|
|
|
| Id |
prsb03-dataelement-12584 (2019‑11‑04 14:01:34)
|
| Concept inherits from |
prsb03-dataelement-12001 (2019‑05‑31 15:12:02)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
Medication discontinued entry
prsb03-dataelement-12585
|
|
|
|
|
Name of discontinued medication
prsb03-dataelement-12586
|
|
|
|
|
Status
prsb03-dataelement-12587
|
|
|
|
|
Status
prsb03-dataelement-12588
|
|
|
|
|
Indication
prsb03-dataelement-12589
|
|
|
|
|
Date of change
prsb03-dataelement-12590
|
|
|
| Id |
prsb03-dataelement-12590 (2019‑11‑04 14:01:34)
|
| Concept inherits from |
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 |
|
|
|
Description of amendment
prsb03-dataelement-12591
|
|
|
|
|
Comment
prsb03-dataelement-12592
|
|
|
|
|
Medical devices entry
prsb03-dataelement-12593
|
|
|
|
|
Medical device
prsb03-dataelement-12594
|
|
|
|
|
Comments
prsb03-dataelement-12595
|
|
|
|
|
Performing Professional
prsb03-dataelement-12596
|
|
|
|
|
Location
prsb03-dataelement-12597
|
|
|
|
|
Date
prsb03-dataelement-12598
|
|
|
|
|
Start date/time
prsb03-dataelement-12599
|
|
|
|
|
Authorised date
prsb03-dataelement-12600
|
|
|
|
|
Valid from date
prsb03-dataelement-12601
|
|
|
|
|
Repeat medications
prsb03-dataelement-12602
|
|
|
|
|
For medications that have been changed
prsb03-dataelement-12603
|
|
|
| Id |
prsb03-dataelement-12603 (2019‑11‑04 14:01:34)
|
| Concept inherits from |
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.
|
|
|
•Prescribed elsewhere
prsb03-dataelement-12604
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
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.
|
|
|
| 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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Services and care
prsb03-dataelement-10044
|
|
|
|
|
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.
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Coded value
prsb03-dataelement-13566
|
|
|
|
|
Free text
prsb03-dataelement-13567
|
|
|
|
|
Care funding source
prsb03-dataelement-13067
|
|
|
| Id |
prsb03-dataelement-13067 (2020‑05‑21 13:41:46)
|
| Concept inherits from |
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 |
|
|
|
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 |
|
|
Name
prsb03-dataelement-11837
|
|
|
| Id |
prsb03-dataelement-11837 (2019‑05‑31 14:29:41)
|
| Concept inherits from |
prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
|
|
Role
prsb03-dataelement-11838
|
|
|
| Id |
prsb03-dataelement-11838 (2019‑05‑31 14:29:41)
|
| Concept inherits from |
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 |
|
|
|
Grade
prsb03-dataelement-11839
|
|
|
| Id |
prsb03-dataelement-11839 (2019‑05‑31 14:29:41)
|
| Concept inherits from |
prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Speciality
prsb03-dataelement-11840
|
|
|
|
|
Professional identifier
prsb03-dataelement-11841
|
|
|
| Id |
prsb03-dataelement-11841 (2019‑05‑31 14:29:41)
|
| Concept inherits from |
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 |
|
|
|
Organisation
prsb03-dataelement-11842
|
|
|
|
|
Contact details
prsb03-dataelement-11843
|
|
|
| Id |
prsb03-dataelement-11843 (2019‑05‑31 14:29:41)
|
| Concept inherits from |
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 |
|
|
|
Person completing record
prsb03-dataelement-11593
|
|
|
|
|
Name
prsb03-dataelement-11594
|
|
|
| Id |
prsb03-dataelement-11594 (2019‑05‑30 15:00:18)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-11595
|
|
|
| Id |
prsb03-dataelement-11595 (2019‑05‑30 15:00:18)
|
| Concept inherits from |
prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-11596
|
|
|
| Id |
prsb03-dataelement-11596 (2019‑05‑30 15:00:18)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-11597
|
|
|
|
|
Organisation
prsb03-dataelement-11598
|
|
|
|
|
Professional identifier
prsb03-dataelement-11599
|
|
|
| Id |
prsb03-dataelement-11599 (2019‑05‑30 15:00:18)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-11600
|
|
|
| Id |
prsb03-dataelement-11600 (2019‑05‑30 15:00:18)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-11601
|
|
|
| Id |
prsb03-dataelement-11601 (2019‑05‑30 15:00:18)
|
| Concept inherits from |
prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
Care needs summary
prsb03-dataelement-13063
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Name
prsb03-dataelement-13182
|
|
|
| Id |
prsb03-dataelement-13182 (2020‑06‑24 17:19:47)
|
| Concept inherits from |
prsb03-dataelement-12028 (2019‑05‑31 15:30:50)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
|
|
Role
prsb03-dataelement-13183
|
|
|
| Id |
prsb03-dataelement-13183 (2020‑06‑24 17:19:47)
|
| Concept inherits from |
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 |
|
|
|
Grade
prsb03-dataelement-13184
|
|
|
| Id |
prsb03-dataelement-13184 (2020‑06‑24 17:19:47)
|
| Concept inherits from |
prsb03-dataelement-12030 (2019‑05‑31 15:30:50)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Speciality
prsb03-dataelement-13185
|
|
|
|
|
Professional identifier
prsb03-dataelement-13186
|
|
|
| Id |
prsb03-dataelement-13186 (2020‑06‑24 17:19:47)
|
| Concept inherits from |
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 |
|
|
|
Organisation
prsb03-dataelement-13187
|
|
|
|
|
Contact details
prsb03-dataelement-13188
|
|
|
| Id |
prsb03-dataelement-13188 (2020‑06‑24 17:19:47)
|
| Concept inherits from |
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 |
|
|
|
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 |
|
|
|
Coded value
prsb03-dataelement-13729
|
|
|
|
|
Free text
prsb03-dataelement-13730
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
Name
prsb03-dataelement-13192
|
|
|
| Id |
prsb03-dataelement-13192 (2020‑06‑24 17:27:59)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Name in dataset prsb03-dataelement-13211
|
|
|
Role
prsb03-dataelement-13193
|
|
|
| Id |
prsb03-dataelement-13193 (2020‑06‑24 17:27:59)
|
| Concept inherits from |
prsb03-dataelement-13102 (2020‑06‑24 16:00:08)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Role in dataset prsb03-dataelement-13212
|
|
|
Grade
prsb03-dataelement-13194
|
|
|
| Id |
prsb03-dataelement-13194 (2020‑06‑24 17:27:59)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Grade in dataset prsb03-dataelement-13213
|
|
|
Specialty
prsb03-dataelement-13195
|
|
|
| Id |
prsb03-dataelement-13195 (2020‑06‑24 17:27:59)
|
| Concept inherits from |
prsb03-dataelement-13104 (2020‑06‑24 16:00:08)
|
| Description |
The main specialty of the person completing the record. |
| FHIR |
PractitionerRole.specialty |
|
| Relationship |
|
| Rationale |
PractitionerRole.speciality |
| Operationalization |
NHS data dictionary :-
Activity treatment function code
|
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-13214
|
|
|
Organisation
prsb03-dataelement-13196
|
|
|
| Id |
prsb03-dataelement-13196 (2020‑06‑24 17:27:59)
|
| Concept inherits from |
prsb03-dataelement-13105 (2020‑06‑24 16:00:08)
|
| Description |
The organisation the person completing the record works for. |
| Relationship |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-13215
|
|
|
Professional identifier
prsb03-dataelement-13197
|
|
|
| Id |
prsb03-dataelement-13197 (2020‑06‑24 17:27:59)
|
| Concept inherits from |
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.
|
| 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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Date completed
prsb03-dataelement-13198
|
|
|
| Id |
prsb03-dataelement-13198 (2020‑06‑24 17:27:59)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-13217
|
|
|
Contact details
prsb03-dataelement-13199
|
|
|
| Id |
prsb03-dataelement-13199 (2020‑06‑24 17:27:59)
|
| Concept inherits from |
prsb03-dataelement-13108 (2020‑06‑24 16:00:08)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-13218
|
|
|
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.
|
|
|
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 |
|
|
|
Person completing record
prsb03-dataelement-13731
|
|
|
| Id |
prsb03-dataelement-13731 (2020‑09‑25 16:25:22)
|
| Concept inherits from |
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 |
|
|
|
Name
prsb03-dataelement-13732
|
|
|
| Id |
prsb03-dataelement-13732 (2020‑09‑25 16:26:25)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-13733
|
|
|
| Id |
prsb03-dataelement-13733 (2020‑09‑25 16:26:25)
|
| Concept inherits from |
prsb03-dataelement-13102 (2020‑06‑24 16:00:08)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-13734
|
|
|
| Id |
prsb03-dataelement-13734 (2020‑09‑25 16:26:25)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-13735
|
|
|
|
|
Organisation
prsb03-dataelement-13736
|
|
|
|
|
Professional identifier
prsb03-dataelement-13737
|
|
|
| Id |
prsb03-dataelement-13737 (2020‑09‑25 16:26:25)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-13738
|
|
|
| Id |
prsb03-dataelement-13738 (2020‑09‑25 16:26:25)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-13739
|
|
|
| Id |
prsb03-dataelement-13739 (2020‑09‑25 16:26:25)
|
| Concept inherits from |
prsb03-dataelement-13108 (2020‑06‑24 16:00:08)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
Person completing record
prsb03-dataelement-13426
|
|
|
|
|
Primary support reason
prsb03-dataelement-12974
|
|
|
|
|
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.
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Family history
prsb03-dataelement-251
|
|
|
|
|
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.
|
|
|
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 |
|
|
|
Location
prsb03-dataelement-10851
|
|
|
|
|
Coded value
prsb03-dataelement-13682
|
|
|
|
|
Free text
prsb03-dataelement-13683
|
|
|
|
|
Performing professional
prsb03-dataelement-11640
|
|
|
| Id |
prsb03-dataelement-11640 (2019‑05‑30 17:58:57)
|
| Description |
The professional who took the family history. |
| Relationship |
|
|
|
Name
prsb03-dataelement-11641
|
|
|
| Id |
prsb03-dataelement-11641 (2019‑05‑30 17:59:44)
|
| Concept inherits from |
prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
|
|
Role
prsb03-dataelement-11642
|
|
|
| Id |
prsb03-dataelement-11642 (2019‑05‑30 17:59:44)
|
| Concept inherits from |
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 |
|
|
|
Grade
prsb03-dataelement-11643
|
|
|
| Id |
prsb03-dataelement-11643 (2019‑05‑30 17:59:44)
|
| Concept inherits from |
prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Speciality
prsb03-dataelement-11644
|
|
|
|
|
Professional identifier
prsb03-dataelement-11645
|
|
|
| Id |
prsb03-dataelement-11645 (2019‑05‑30 17:59:44)
|
| Concept inherits from |
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 |
|
|
|
Organisation
prsb03-dataelement-11646
|
|
|
|
|
Contact details
prsb03-dataelement-11647
|
|
|
| Id |
prsb03-dataelement-11647 (2019‑05‑30 17:59:44)
|
| Concept inherits from |
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 |
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
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. |
|
|
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 |
|
|
|
Free text
prsb03-dataelement-13677
|
|
|
|
|
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.
|
|
|
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 |
|
|
|
Free text
prsb03-dataelement-13679
|
|
|
|
|
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.
|
|
|
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 |
|
|
|
Free text
prsb03-dataelement-13681
|
|
|
|
|
Person completing record
prsb03-dataelement-11630
|
|
|
|
|
Name
prsb03-dataelement-11631
|
|
|
| Id |
prsb03-dataelement-11631 (2019‑05‑30 15:28:41)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-11632
|
|
|
| Id |
prsb03-dataelement-11632 (2019‑05‑30 15:28:41)
|
| Concept inherits from |
prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-11633
|
|
|
| Id |
prsb03-dataelement-11633 (2019‑05‑30 15:28:41)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-11634
|
|
|
|
|
Organisation
prsb03-dataelement-11635
|
|
|
|
|
Professional identifier
prsb03-dataelement-11636
|
|
|
| Id |
prsb03-dataelement-11636 (2019‑05‑30 15:28:41)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-11637
|
|
|
| Id |
prsb03-dataelement-11637 (2019‑05‑30 15:28:41)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-11638
|
|
|
| Id |
prsb03-dataelement-11638 (2019‑05‑30 15:28:41)
|
| Concept inherits from |
prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
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 |
|
|
|
Comment
prsb03-dataelement-10156
|
|
|
| Id |
prsb03-dataelement-10156 (2018‑10‑31)
|
| Description |
Any further textual comment. |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Investigation results
prsb03-dataelement-257
|
|
|
|
|
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.
|
|
|
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 |
|
|
|
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 |
|
|
|
Performing professional
prsb03-dataelement-12099
|
|
|
| Id |
prsb03-dataelement-12099 (2019‑05‑31 15:55:11)
|
| Description |
The professional who performed the investigation. |
| Relationship |
|
|
|
Name
prsb03-dataelement-12100
|
|
|
| Id |
prsb03-dataelement-12100 (2019‑05‑31 15:55:33)
|
| Concept inherits from |
prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
|
|
Role
prsb03-dataelement-12101
|
|
|
| Id |
prsb03-dataelement-12101 (2019‑05‑31 15:55:33)
|
| Concept inherits from |
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 |
|
|
|
Grade
prsb03-dataelement-12102
|
|
|
| Id |
prsb03-dataelement-12102 (2019‑05‑31 15:55:33)
|
| Concept inherits from |
prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Speciality
prsb03-dataelement-12103
|
|
|
|
|
Professional identifier
prsb03-dataelement-12104
|
|
|
| Id |
prsb03-dataelement-12104 (2019‑05‑31 15:55:33)
|
| Concept inherits from |
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 |
|
|
|
Organisation
prsb03-dataelement-12105
|
|
|
|
|
Contact details
prsb03-dataelement-12106
|
|
|
| Id |
prsb03-dataelement-12106 (2019‑05‑31 15:55:33)
|
| Concept inherits from |
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 |
|
|
|
Location
prsb03-dataelement-10159
|
|
|
|
|
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 |
|
|
|
Free text
prsb03-dataelement-13726
|
|
|
|
|
Investigation
prsb03-dataelement-10160
|
|
|
|
|
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 |
|
|
|
Free text
prsb03-dataelement-13526
|
|
|
|
|
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.
|
|
|
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 |
|
|
|
Free text
prsb03-dataelement-13528
|
|
|
|
|
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 |
|
|
|
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. |
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Person completing record
prsb03-dataelement-12107
|
|
|
|
|
Name
prsb03-dataelement-12108
|
|
|
| Id |
prsb03-dataelement-12108 (2019‑05‑31 15:56:17)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-12109
|
|
|
| Id |
prsb03-dataelement-12109 (2019‑05‑31 15:56:17)
|
| Concept inherits from |
prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-12110
|
|
|
| Id |
prsb03-dataelement-12110 (2019‑05‑31 15:56:17)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-12111
|
|
|
|
|
Organisation
prsb03-dataelement-12112
|
|
|
|
|
Professional identifier
prsb03-dataelement-12113
|
|
|
| Id |
prsb03-dataelement-12113 (2019‑05‑31 15:56:17)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-12114
|
|
|
| Id |
prsb03-dataelement-12114 (2019‑05‑31 15:56:17)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-12115
|
|
|
| Id |
prsb03-dataelement-12115 (2019‑05‑31 15:56:17)
|
| Concept inherits from |
prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
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 |
|
|
|
Signpost details
prsb03-dataelement-13973
|
|
|
|
|
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.
|
|
|
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 |
|
|
|
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
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Service
prsb03-dataelement-13982
|
|
|
|
|
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 |
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Free text in dataset prsb03-dataelement-14266
|
|
|
Organisation
prsb03-dataelement-13985
|
|
|
| Id |
prsb03-dataelement-13985 (2021‑02‑11 12:48:00)
|
| Description |
Name of organisation been signposted to. |
| Operationalization |
Free text
|
|
|
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 |
|
|
|
Coded value
prsb03-dataelement-13986
|
|
|
|
|
Reason for signpost
prsb03-dataelement-13988
|
|
|
|
|
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 |
|
|
|
Free text
prsb03-dataelement-13990
|
|
|
|
|
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
|
|
|
Investigations requested
prsb03-dataelement-10730
|
|
|
|
|
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.
|
|
|
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 |
|
|
|
Location
prsb03-dataelement-10736
|
|
|
|
|
Coded value
prsb03-dataelement-13727
|
|
|
|
|
Free text
prsb03-dataelement-13728
|
|
|
|
|
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 |
|
|
|
Performing professional
prsb03-dataelement-12081
|
|
|
| Id |
prsb03-dataelement-12081 (2019‑05‑31 15:49:09)
|
| Description |
The professional who requested the investigation. |
| Relationship |
|
|
|
Name
prsb03-dataelement-12082
|
|
|
| Id |
prsb03-dataelement-12082 (2019‑05‑31 15:49:33)
|
| Concept inherits from |
prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
|
|
Role
prsb03-dataelement-12083
|
|
|
| Id |
prsb03-dataelement-12083 (2019‑05‑31 15:49:33)
|
| Concept inherits from |
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 |
|
|
|
Grade
prsb03-dataelement-12084
|
|
|
| Id |
prsb03-dataelement-12084 (2019‑05‑31 15:49:33)
|
| Concept inherits from |
prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Speciality
prsb03-dataelement-12085
|
|
|
|
|
Professional identifier
prsb03-dataelement-12086
|
|
|
| Id |
prsb03-dataelement-12086 (2019‑05‑31 15:49:33)
|
| Concept inherits from |
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 |
|
|
|
Organisation
prsb03-dataelement-12087
|
|
|
|
|
Contact details
prsb03-dataelement-12088
|
|
|
| Id |
prsb03-dataelement-12088 (2019‑05‑31 15:49:33)
|
| Concept inherits from |
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 |
|
|
|
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)
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
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 |
|
|
|
Free text
prsb03-dataelement-13530
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
prsb03-dataelement-12089
|
|
|
|
|
Person completing record
prsb03-dataelement-12090
|
|
|
|
|
Name
prsb03-dataelement-12091
|
|
|
| Id |
prsb03-dataelement-12091 (2019‑05‑31 15:50:55)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-12092
|
|
|
| Id |
prsb03-dataelement-12092 (2019‑05‑31 15:50:55)
|
| Concept inherits from |
prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-12093
|
|
|
| Id |
prsb03-dataelement-12093 (2019‑05‑31 15:50:55)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-12094
|
|
|
|
|
Organisation
prsb03-dataelement-12095
|
|
|
|
|
Professional identifier
prsb03-dataelement-12096
|
|
|
| Id |
prsb03-dataelement-12096 (2019‑05‑31 15:50:55)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-12097
|
|
|
| Id |
prsb03-dataelement-12097 (2019‑05‑31 15:50:55)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-12098
|
|
|
| Id |
prsb03-dataelement-12098 (2019‑05‑31 15:50:55)
|
| Concept inherits from |
prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
Observations
prsb03-dataelement-12475
|
|
|
|
|
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 |
|
|
|
Examination findings
prsb03-dataelement-557
|
|
|
|
|
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.
|
|
|
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 |
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Performing professional
prsb03-dataelement-12116
|
|
|
| Id |
prsb03-dataelement-12116 (2019‑05‑31 15:59:16)
|
| Description |
The professional who performed the examiniation. |
| Relationship |
|
|
|
Name
prsb03-dataelement-12117
|
|
|
| Id |
prsb03-dataelement-12117 (2019‑05‑31 15:59:38)
|
| Concept inherits from |
prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
|
|
Role
prsb03-dataelement-12118
|
|
|
| Id |
prsb03-dataelement-12118 (2019‑05‑31 15:59:38)
|
| Concept inherits from |
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 |
|
|
|
Grade
prsb03-dataelement-12119
|
|
|
| Id |
prsb03-dataelement-12119 (2019‑05‑31 15:59:38)
|
| Concept inherits from |
prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Speciality
prsb03-dataelement-12120
|
|
|
|
|
Professional identifier
prsb03-dataelement-12121
|
|
|
| Id |
prsb03-dataelement-12121 (2019‑05‑31 15:59:38)
|
| Concept inherits from |
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 |
|
|
|
Organisation
prsb03-dataelement-12122
|
|
|
|
|
Contact details
prsb03-dataelement-12123
|
|
|
| Id |
prsb03-dataelement-12123 (2019‑05‑31 15:59:38)
|
| Concept inherits from |
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 |
|
|
|
Location
prsb03-dataelement-10461
|
|
|
|
|
Coded value
prsb03-dataelement-13445
|
|
|
|
|
Free text
prsb03-dataelement-13446
|
|
|
|
|
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 |
|
|
|
Examination findings
prsb03-dataelement-10458
|
|
|
|
|
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 |
|
|
|
Free text
prsb03-dataelement-13444
|
|
|
|
|
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 |
|
|
|
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.
|
|
|
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.
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Free text
prsb03-dataelement-13448
|
|
|
|
|
News 2 score
prsb03-dataelement-13860
|
|
|
|
|
Height/length
prsb03-dataelement-13761
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Weight
prsb03-dataelement-13814
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
BMI
prsb03-dataelement-13819
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Blood pressure
prsb03-dataelement-13823
|
|
|
|
|
Systolic blood pressure
prsb03-dataelement-13824
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
| FHIR |
MedicationStatement.dosage.site |
|
| Relationship |
|
|
|
Coded value
prsb03-dataelement-13830
|
|
|
| Id |
prsb03-dataelement-13830 (2020‑12‑18 19:11:37)
|
| Concept inherits from |
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 |
|
|
|
Free text
prsb03-dataelement-13831
|
|
|
|
|
Site
prsb03-dataelement-13828
|
|
|
| Id |
prsb03-dataelement-13828 (2020‑12‑18 18:59:29) 0.1
|
| Concept inherits from |
prsb03-dataelement-13204 (2020‑06‑24 17:51:17)
|
| Description |
The anatomical site at which the medication is administered. |
| 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 |
|
|
|
Diastolic blood pressure
prsb03-dataelement-13867
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Site
prsb03-dataelement-13871
|
|
|
|
|
Coded value
prsb03-dataelement-13872
|
|
|
| Id |
prsb03-dataelement-13872 (2021‑01‑27 18:51:09)
|
| Concept inherits from |
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 |
|
|
|
Free text
prsb03-dataelement-13873
|
|
|
|
|
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
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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)
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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) |
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Pain score
prsb03-dataelement-14243
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Level of conciousness
prsb03-dataelement-14247
|
|
|
|
|
prsb03-dataelement-14250
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Respiratory rate
prsb03-dataelement-14248
|
|
|
|
|
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 |
|
|
|
Value
prsb03-dataelement-14255
|
|
|
| Id |
prsb03-dataelement-14255 (2021‑03‑05 15:14:26)
|
| Description |
Value for respiratory rate |
| Operationalization |
Numeric |
| Value Domain |
|
|
|
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 |
|
|
|
Air or Oxygen
prsb03-dataelement-14257
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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
-
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Subscore
prsb03-dataelement-13865
|
|
|
| Id |
prsb03-dataelement-13865 (2021‑01‑27 17:43:11)
|
| Description |
Subscore from each NEWS2 observation |
| Operationalization |
Numeric |
| Value Domain |
|
|
|
Person completing record
prsb03-dataelement-12124
|
|
|
|
|
Name
prsb03-dataelement-12125
|
|
|
| Id |
prsb03-dataelement-12125 (2019‑05‑31 16:00:31)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-12126
|
|
|
| Id |
prsb03-dataelement-12126 (2019‑05‑31 16:00:31)
|
| Concept inherits from |
prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-12127
|
|
|
| Id |
prsb03-dataelement-12127 (2019‑05‑31 16:00:31)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-12128
|
|
|
|
|
Organisation
prsb03-dataelement-12129
|
|
|
|
|
Professional identifier
prsb03-dataelement-12130
|
|
|
| Id |
prsb03-dataelement-12130 (2019‑05‑31 16:00:31)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-12131
|
|
|
| Id |
prsb03-dataelement-12131 (2019‑05‑31 16:00:31)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-12132
|
|
|
| Id |
prsb03-dataelement-12132 (2019‑05‑31 16:00:31)
|
| Concept inherits from |
prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Oral examination
prsb03-dataelement-10467
|
|
|
|
|
Cardiovascular examination
prsb03-dataelement-10468
|
|
|
| Id |
prsb03-dataelement-10468 (2018‑10‑31)
|
| Description |
The record of findings from the cardiovascular system examination. |
| Value Domain |
|
|
|
Respiratory examination
prsb03-dataelement-10469
|
|
|
| Id |
prsb03-dataelement-10469 (2018‑10‑31)
|
| Description |
The record of findings from the respiratory system examination. |
| Value Domain |
|
|
|
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 |
|
|
|
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 |
|
|
|
Musculoskeletal examination
prsb03-dataelement-10472
|
|
|
| Id |
prsb03-dataelement-10472 (2018‑10‑31)
|
| Description |
The record of findings from the musculoskeletal examination |
| Value Domain |
|
|
|
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 |
|
|
|
Abdomen examination
prsb03-dataelement-10474
|
|
|
| Id |
prsb03-dataelement-10474 (2018‑10‑31)
|
| Description |
The record of findings from the abdominal examination. |
| Value Domain |
|
|
|
Genitourinary examination
prsb03-dataelement-10475
|
|
|
| Id |
prsb03-dataelement-10475 (2018‑10‑31)
|
| Description |
The record of findings from the genitourinary examination. |
| Value Domain |
|
|
|
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 |
|
|
|
Fetal Examinations
prsb03-dataelement-10477
|
|
|
|
|
Current pregnancy
prsb03-dataelement-10814
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Coded value
prsb03-dataelement-13531
|
|
|
|
|
Free text
prsb03-dataelement-13532
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
Performing professional
prsb03-dataelement-13533
|
|
|
|
|
Name
prsb03-dataelement-13534
|
|
|
| Id |
prsb03-dataelement-13534 (2020‑09‑04 16:32:32)
|
| Concept inherits from |
prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
|
|
Role
prsb03-dataelement-13535
|
|
|
| Id |
prsb03-dataelement-13535 (2020‑09‑04 16:32:32)
|
| Concept inherits from |
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 |
|
|
|
Grade
prsb03-dataelement-13536
|
|
|
| Id |
prsb03-dataelement-13536 (2020‑09‑04 16:32:32)
|
| Concept inherits from |
prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Speciality
prsb03-dataelement-13537
|
|
|
|
|
Professional identifier
prsb03-dataelement-13538
|
|
|
| Id |
prsb03-dataelement-13538 (2020‑09‑04 16:32:32)
|
| Concept inherits from |
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 |
|
|
|
Organisation
prsb03-dataelement-13539
|
|
|
|
|
Coded value
prsb03-dataelement-13540
|
|
|
|
|
Free text
prsb03-dataelement-13541
|
|
|
|
|
Contact details
prsb03-dataelement-13542
|
|
|
| Id |
prsb03-dataelement-13542 (2020‑09‑04 16:32:32)
|
| Concept inherits from |
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 |
|
|
|
Person completing record
prsb03-dataelement-13543
|
|
|
|
|
Name
prsb03-dataelement-13544
|
|
|
| Id |
prsb03-dataelement-13544 (2020‑09‑04 16:33:48)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-13545
|
|
|
| Id |
prsb03-dataelement-13545 (2020‑09‑04 16:33:48)
|
| Concept inherits from |
prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-13546
|
|
|
| Id |
prsb03-dataelement-13546 (2020‑09‑04 16:33:48)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-13547
|
|
|
|
|
Organisation
prsb03-dataelement-13548
|
|
|
|
|
Coded value
prsb03-dataelement-13549
|
|
|
|
|
Free text
prsb03-dataelement-13550
|
|
|
|
|
Professional identifier
prsb03-dataelement-13551
|
|
|
| Id |
prsb03-dataelement-13551 (2020‑09‑04 16:33:48)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-13552
|
|
|
| Id |
prsb03-dataelement-13552 (2020‑09‑04 16:33:48)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-13553
|
|
|
| Id |
prsb03-dataelement-13553 (2020‑09‑04 16:33:48)
|
| Concept inherits from |
prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
Maternity Personalised Care Plan
prsb03-dataelement-10839
|
|
|
|
|
Previous pregnancies
prsb03-dataelement-10827
|
|
|
|
|
Date
prsb03-dataelement-10829
|
|
|
|
|
Date and Time of Delivery
prsb03-dataelement-10836
|
|
|
|
|
Location
prsb03-dataelement-10830
|
|
|
|
|
Performing Professional
prsb03-dataelement-10831
|
|
|
| Id |
prsb03-dataelement-10831 (2019‑03‑21 15:32:29)
|
| Concept inherits from |
prsb03-dataelement-10492 (2018‑10‑31)
|
| Description |
Details of the professional recording the pregnancy outcome/delivery/birth details
(including name and role).
|
| Value Domain |
|
|
|
Pregnancy Outcome
prsb03-dataelement-10828
|
|
|
|
|
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 |
|
|
|
Investigation requests and results
prsb03-dataelement-10833
|
|
|
|
|
Investigation requested
prsb03-dataelement-10834
|
|
|
| Id |
prsb03-dataelement-10834 (2019‑03‑21 15:45:23)
|
| Concept inherits from |
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)
|
|
|
Status of pregnancy
prsb03-dataelement-10805
|
|
|
|
|
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 |
|
|
|
Structured Description
prsb03-dataelement-10807
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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)
|
| Data Type |
Healthcare Provider |
|
| Value Domain |
|
|
|
Assessments
prsb03-dataelement-262
|
|
|
|
|
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.
|
|
|
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 |
|
|
|
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 |
|
|
|
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. |
|
|
Coded value
prsb03-dataelement-13570
|
|
|
|
|
Free text
prsb03-dataelement-13571
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Structured assessment
prsb03-dataelement-10655
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Performing professional
prsb03-dataelement-12390
|
|
|
| Id |
prsb03-dataelement-12390 (2019‑06‑03 16:03:07)
|
| Description |
The professional who did the structured assessment. |
| Relationship |
|
|
|
Name
prsb03-dataelement-12391
|
|
|
| Id |
prsb03-dataelement-12391 (2019‑06‑03 16:03:28)
|
| Concept inherits from |
prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
|
|
Role
prsb03-dataelement-12392
|
|
|
| Id |
prsb03-dataelement-12392 (2019‑06‑03 16:03:28)
|
| Concept inherits from |
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 |
|
|
|
Grade
prsb03-dataelement-12393
|
|
|
| Id |
prsb03-dataelement-12393 (2019‑06‑03 16:03:28)
|
| Concept inherits from |
prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Speciality
prsb03-dataelement-12394
|
|
|
|
|
Professional identifier
prsb03-dataelement-12395
|
|
|
| Id |
prsb03-dataelement-12395 (2019‑06‑03 16:03:28)
|
| Concept inherits from |
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 |
|
|
|
Organisation
prsb03-dataelement-12396
|
|
|
|
|
Contact details
prsb03-dataelement-12397
|
|
|
| Id |
prsb03-dataelement-12397 (2019‑06‑03 16:03:28)
|
| Concept inherits from |
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 |
|
|
|
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 |
|
|
|
Assessment score
prsb03-dataelement-10162
|
|
|
| Id |
prsb03-dataelement-10162 (2018‑10‑31)
|
| Description |
The structured assessment score. |
| Operationalization |
Free text. |
| Value Domain |
|
|
|
Assessment value
prsb03-dataelement-10163
|
|
|
| Id |
prsb03-dataelement-10163 (2018‑10‑31)
|
| Description |
The structured assessment value. |
| Operationalization |
Numeric |
| Value Domain |
|
|
|
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 |
|
|
|
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 |
|
|
|
Subscale value
prsb03-dataelement-10170
|
|
|
| Id |
prsb03-dataelement-10170 (2018‑10‑31)
|
| Description |
The subscale value of the structured assessment. |
| Operationalization |
Numeric |
| Value Domain |
|
|
|
Person completing record
prsb03-dataelement-11761
|
|
|
|
|
Name
prsb03-dataelement-11762
|
|
|
| Id |
prsb03-dataelement-11762 (2019‑05‑31 14:10:49)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-11763
|
|
|
| Id |
prsb03-dataelement-11763 (2019‑05‑31 14:10:49)
|
| Concept inherits from |
prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-11764
|
|
|
| Id |
prsb03-dataelement-11764 (2019‑05‑31 14:10:49)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-11765
|
|
|
|
|
Organisation
prsb03-dataelement-11766
|
|
|
|
|
Professional identifier
prsb03-dataelement-11767
|
|
|
| Id |
prsb03-dataelement-11767 (2019‑05‑31 14:10:49)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-11768
|
|
|
| Id |
prsb03-dataelement-11768 (2019‑05‑31 14:10:49)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-11769
|
|
|
| Id |
prsb03-dataelement-11769 (2019‑05‑31 14:10:49)
|
| Concept inherits from |
prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
Person completing record
prsb03-dataelement-10962
|
|
|
| Id |
prsb03-dataelement-10962 (2019‑05‑18 21:30:43)
|
| Concept inherits from |
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 |
|
|
|
Performing professional
prsb03-dataelement-12382
|
|
|
|
|
Name
prsb03-dataelement-12383
|
|
|
| Id |
prsb03-dataelement-12383 (2019‑06‑03 16:02:46)
|
| Concept inherits from |
prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
|
|
Role
prsb03-dataelement-12384
|
|
|
| Id |
prsb03-dataelement-12384 (2019‑06‑03 16:02:46)
|
| Concept inherits from |
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 |
|
|
|
Grade
prsb03-dataelement-12385
|
|
|
| Id |
prsb03-dataelement-12385 (2019‑06‑03 16:02:46)
|
| Concept inherits from |
prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Speciality
prsb03-dataelement-12386
|
|
|
|
|
Professional identifier
prsb03-dataelement-12387
|
|
|
| Id |
prsb03-dataelement-12387 (2019‑06‑03 16:02:46)
|
| Concept inherits from |
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 |
|
|
|
Organisation
prsb03-dataelement-12388
|
|
|
|
|
Contact details
prsb03-dataelement-12389
|
|
|
| Id |
prsb03-dataelement-12389 (2019‑06‑03 16:02:46)
|
| Concept inherits from |
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 |
|
|
|
Person completing record
prsb03-dataelement-11752
|
|
|
|
|
Name
prsb03-dataelement-11753
|
|
|
| Id |
prsb03-dataelement-11753 (2019‑05‑31 14:08:52)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-11754
|
|
|
| Id |
prsb03-dataelement-11754 (2019‑05‑31 14:08:52)
|
| Concept inherits from |
prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-11755
|
|
|
| Id |
prsb03-dataelement-11755 (2019‑05‑31 14:08:52)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-11756
|
|
|
|
|
Organisation
prsb03-dataelement-11757
|
|
|
|
|
Professional identifier
prsb03-dataelement-11758
|
|
|
| Id |
prsb03-dataelement-11758 (2019‑05‑31 14:08:52)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-11759
|
|
|
| Id |
prsb03-dataelement-11759 (2019‑05‑31 14:08:52)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-11760
|
|
|
| Id |
prsb03-dataelement-11760 (2019‑05‑31 14:08:52)
|
| Concept inherits from |
prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
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 |
|
|
|
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.
|
| 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
|
|
|
Formulation
prsb03-dataelement-10749
|
|
|
| Id |
prsb03-dataelement-10749 (2019‑03‑07 14:50:29)
|
| Concept inherits from |
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 |
|
|
|
Mental capacity assessment
prsb03-dataelement-10757
|
|
|
|
|
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 |
|
|
|
Clinical summary
prsb03-dataelement-10750
|
|
|
| Id |
prsb03-dataelement-10750 (2019‑03‑07 17:13:57) Not needed
|
| Concept inherits from |
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 |
|
|
|
Formulation
prsb03-dataelement-11666
|
|
|
|
|
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.
|
|
|
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 |
|
|
|
Location
prsb03-dataelement-11670
|
|
|
|
|
Coded value
prsb03-dataelement-13572
|
|
|
|
|
Free text
prsb03-dataelement-13573
|
|
|
|
|
Performing professional
prsb03-dataelement-11671
|
|
|
|
|
Name
prsb03-dataelement-11672
|
|
|
| Id |
prsb03-dataelement-11672 (2019‑05‑30 20:49:34)
|
| Concept inherits from |
prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
|
|
Role
prsb03-dataelement-11673
|
|
|
| Id |
prsb03-dataelement-11673 (2019‑05‑30 20:49:34)
|
| Concept inherits from |
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 |
|
|
|
Grade
prsb03-dataelement-11674
|
|
|
| Id |
prsb03-dataelement-11674 (2019‑05‑30 20:49:34)
|
| Concept inherits from |
prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Speciality
prsb03-dataelement-11675
|
|
|
|
|
Professional identifier
prsb03-dataelement-11676
|
|
|
| Id |
prsb03-dataelement-11676 (2019‑05‑30 20:49:34)
|
| Concept inherits from |
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 |
|
|
|
Organisation
prsb03-dataelement-11677
|
|
|
|
|
Contact details
prsb03-dataelement-11678
|
|
|
| Id |
prsb03-dataelement-11678 (2019‑05‑30 20:49:34)
|
| Concept inherits from |
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 |
|
|
|
Formulation
prsb03-dataelement-11668
|
|
|
| Id |
prsb03-dataelement-11668 (2019‑05‑30 20:46:15)
|
| Concept inherits from |
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 |
|
|
|
Person completing record
prsb03-dataelement-11679
|
|
|
|
|
Name
prsb03-dataelement-11680
|
|
|
| Id |
prsb03-dataelement-11680 (2019‑05‑30 20:50:13)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-11681
|
|
|
| Id |
prsb03-dataelement-11681 (2019‑05‑30 20:50:13)
|
| Concept inherits from |
prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-11682
|
|
|
| Id |
prsb03-dataelement-11682 (2019‑05‑30 20:50:13)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-11683
|
|
|
|
|
Organisation
prsb03-dataelement-11684
|
|
|
|
|
Professional identifier
prsb03-dataelement-11685
|
|
|
| Id |
prsb03-dataelement-11685 (2019‑05‑30 20:50:13)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-11686
|
|
|
| Id |
prsb03-dataelement-11686 (2019‑05‑30 20:50:13)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-11687
|
|
|
| Id |
prsb03-dataelement-11687 (2019‑05‑30 20:50:13)
|
| Concept inherits from |
prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
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 |
|
|
|
Risks
prsb03-dataelement-276
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
Risks to self
prsb03-dataelement-10176
|
|
|
|
|
Start date of risk
prsb03-dataelement-11893
|
|
|
| Id |
prsb03-dataelement-11893 (2019‑05‑31 14:50:40)
|
| Concept inherits from |
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 |
|
|
|
End date of risk
prsb03-dataelement-11894
|
|
|
| Id |
prsb03-dataelement-11894 (2019‑05‑31 14:51:05)
|
| Concept inherits from |
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 |
|
|
|
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 |
|
|
|
Location
prsb03-dataelement-11895
|
|
|
|
|
Coded value
prsb03-dataelement-13586
|
|
|
|
|
Free text
prsb03-dataelement-13587
|
|
|
|
|
Performing professional
prsb03-dataelement-11896
|
|
|
|
|
Name
prsb03-dataelement-11897
|
|
|
| Id |
prsb03-dataelement-11897 (2019‑05‑31 14:52:54)
|
| Concept inherits from |
prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
|
|
Role
prsb03-dataelement-11898
|
|
|
| Id |
prsb03-dataelement-11898 (2019‑05‑31 14:52:54)
|
| Concept inherits from |
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 |
|
|
|
Grade
prsb03-dataelement-11899
|
|
|
| Id |
prsb03-dataelement-11899 (2019‑05‑31 14:52:54)
|
| Concept inherits from |
prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Speciality
prsb03-dataelement-11900
|
|
|
|
|
Professional identifier
prsb03-dataelement-11901
|
|
|
| Id |
prsb03-dataelement-11901 (2019‑05‑31 14:52:54)
|
| Concept inherits from |
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 |
|
|
|
Organisation
prsb03-dataelement-11902
|
|
|
|
|
Contact details
prsb03-dataelement-11903
|
|
|
| Id |
prsb03-dataelement-11903 (2019‑05‑31 14:52:54)
|
| Concept inherits from |
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 |
|
|
|
Person completing record
prsb03-dataelement-11904
|
|
|
|
|
Name
prsb03-dataelement-11905
|
|
|
| Id |
prsb03-dataelement-11905 (2019‑05‑31 14:53:43)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-11906
|
|
|
| Id |
prsb03-dataelement-11906 (2019‑05‑31 14:53:43)
|
| Concept inherits from |
prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-11907
|
|
|
| Id |
prsb03-dataelement-11907 (2019‑05‑31 14:53:43)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-11908
|
|
|
|
|
Organisation
prsb03-dataelement-11909
|
|
|
|
|
Professional identifier
prsb03-dataelement-11910
|
|
|
| Id |
prsb03-dataelement-11910 (2019‑05‑31 14:53:43)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-11911
|
|
|
| Id |
prsb03-dataelement-11911 (2019‑05‑31 14:53:43)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-11912
|
|
|
| Id |
prsb03-dataelement-11912 (2019‑05‑31 14:53:43)
|
| Concept inherits from |
prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
Date of self harm
prsb03-dataelement-10823
|
|
|
|
|
Risks to others
prsb03-dataelement-10177
|
|
|
|
|
Start date of risk
prsb03-dataelement-11913
|
|
|
| Id |
prsb03-dataelement-11913 (2019‑05‑31 14:54:14)
|
| Concept inherits from |
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 |
|
|
|
End date of risk
prsb03-dataelement-11914
|
|
|
| Id |
prsb03-dataelement-11914 (2019‑05‑31 14:54:38)
|
| Concept inherits from |
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Coded value
prsb03-dataelement-13588
|
|
|
|
|
Free text
prsb03-dataelement-13589
|
|
|
|
|
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 |
|
|
|
Name
prsb03-dataelement-11917
|
|
|
| Id |
prsb03-dataelement-11917 (2019‑05‑31 14:55:55)
|
| Concept inherits from |
prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
|
|
Role
prsb03-dataelement-11918
|
|
|
| Id |
prsb03-dataelement-11918 (2019‑05‑31 14:55:55)
|
| Concept inherits from |
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 |
|
|
|
Grade
prsb03-dataelement-11919
|
|
|
| Id |
prsb03-dataelement-11919 (2019‑05‑31 14:55:55)
|
| Concept inherits from |
prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Speciality
prsb03-dataelement-11920
|
|
|
|
|
Professional identifier
prsb03-dataelement-11921
|
|
|
| Id |
prsb03-dataelement-11921 (2019‑05‑31 14:55:55)
|
| Concept inherits from |
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 |
|
|
|
Organisation
prsb03-dataelement-11922
|
|
|
|
|
Contact details
prsb03-dataelement-11923
|
|
|
| Id |
prsb03-dataelement-11923 (2019‑05‑31 14:55:55)
|
| Concept inherits from |
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 |
|
|
|
Person completing record
prsb03-dataelement-11924
|
|
|
|
|
Name
prsb03-dataelement-11925
|
|
|
| Id |
prsb03-dataelement-11925 (2019‑05‑31 14:57:11)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-11926
|
|
|
| Id |
prsb03-dataelement-11926 (2019‑05‑31 14:57:11)
|
| Concept inherits from |
prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-11927
|
|
|
| Id |
prsb03-dataelement-11927 (2019‑05‑31 14:57:11)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-11928
|
|
|
|
|
Organisation
prsb03-dataelement-11929
|
|
|
|
|
Professional identifier
prsb03-dataelement-11930
|
|
|
| Id |
prsb03-dataelement-11930 (2019‑05‑31 14:57:11)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-11931
|
|
|
| Id |
prsb03-dataelement-11931 (2019‑05‑31 14:57:11)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-11932
|
|
|
| Id |
prsb03-dataelement-11932 (2019‑05‑31 14:57:11)
|
| Concept inherits from |
prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
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. |
|
|
| Operationalization |
Free Text. |
|
|
Start date of risk
prsb03-dataelement-11933
|
|
|
| Id |
prsb03-dataelement-11933 (2019‑05‑31 14:58:12)
|
| Concept inherits from |
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 |
|
|
|
End date of risk
prsb03-dataelement-11934
|
|
|
| Id |
prsb03-dataelement-11934 (2019‑05‑31 14:58:38)
|
| Concept inherits from |
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Coded value
prsb03-dataelement-13590
|
|
|
|
|
Free text
prsb03-dataelement-13591
|
|
|
|
|
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 |
|
|
|
Name
prsb03-dataelement-11937
|
|
|
| Id |
prsb03-dataelement-11937 (2019‑05‑31 14:59:53)
|
| Concept inherits from |
prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
|
|
Role
prsb03-dataelement-11938
|
|
|
| Id |
prsb03-dataelement-11938 (2019‑05‑31 14:59:53)
|
| Concept inherits from |
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 |
|
|
|
Grade
prsb03-dataelement-11939
|
|
|
| Id |
prsb03-dataelement-11939 (2019‑05‑31 14:59:53)
|
| Concept inherits from |
prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Speciality
prsb03-dataelement-11940
|
|
|
|
|
Professional identifier
prsb03-dataelement-11941
|
|
|
| Id |
prsb03-dataelement-11941 (2019‑05‑31 14:59:53)
|
| Concept inherits from |
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 |
|
|
|
Organisation
prsb03-dataelement-11942
|
|
|
|
|
Contact details
prsb03-dataelement-11943
|
|
|
| Id |
prsb03-dataelement-11943 (2019‑05‑31 14:59:53)
|
| Concept inherits from |
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 |
|
|
|
Person completing record
prsb03-dataelement-11944
|
|
|
|
|
Name
prsb03-dataelement-11945
|
|
|
| Id |
prsb03-dataelement-11945 (2019‑05‑31 15:00:27)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-11946
|
|
|
| Id |
prsb03-dataelement-11946 (2019‑05‑31 15:00:27)
|
| Concept inherits from |
prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-11947
|
|
|
| Id |
prsb03-dataelement-11947 (2019‑05‑31 15:00:27)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-11948
|
|
|
|
|
Organisation
prsb03-dataelement-11949
|
|
|
|
|
Professional identifier
prsb03-dataelement-11950
|
|
|
| Id |
prsb03-dataelement-11950 (2019‑05‑31 15:00:27)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-11951
|
|
|
| Id |
prsb03-dataelement-11951 (2019‑05‑31 15:00:27)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-11952
|
|
|
| Id |
prsb03-dataelement-11952 (2019‑05‑31 15:00:27)
|
| Concept inherits from |
prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
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. |
|
|
Start date of risk
prsb03-dataelement-11953
|
|
|
| Id |
prsb03-dataelement-11953 (2019‑05‑31 15:00:58)
|
| Concept inherits from |
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 |
|
|
|
End date of risk
prsb03-dataelement-11954
|
|
|
| Id |
prsb03-dataelement-11954 (2019‑05‑31 15:01:29)
|
| Concept inherits from |
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Coded value
prsb03-dataelement-13592
|
|
|
|
|
Free text
prsb03-dataelement-13593
|
|
|
|
|
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 |
|
|
|
Name
prsb03-dataelement-11957
|
|
|
| Id |
prsb03-dataelement-11957 (2019‑05‑31 15:02:41)
|
| Concept inherits from |
prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Name in dataset prsb03-dataelement-13598
|
|
|
Role
prsb03-dataelement-11958
|
|
|
| Id |
prsb03-dataelement-11958 (2019‑05‑31 15:02:41)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Role in dataset prsb03-dataelement-13599
|
|
|
Grade
prsb03-dataelement-11959
|
|
|
| Id |
prsb03-dataelement-11959 (2019‑05‑31 15:02:41)
|
| Concept inherits from |
prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Grade in dataset prsb03-dataelement-13600
|
|
|
Speciality
prsb03-dataelement-11960
|
|
|
| Id |
prsb03-dataelement-11960 (2019‑05‑31 15:02:41)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-13601
|
|
|
Professional identifier
prsb03-dataelement-11961
|
|
|
| Id |
prsb03-dataelement-11961 (2019‑05‑31 15:02:41)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Organisation
prsb03-dataelement-11962
|
|
|
| Id |
prsb03-dataelement-11962 (2019‑05‑31 15:02:41)
|
| Concept inherits from |
prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
|
| Description |
The name of the organisation the professional works for. |
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-13603
|
|
|
Contact details
prsb03-dataelement-11963
|
|
|
| Id |
prsb03-dataelement-11963 (2019‑05‑31 15:02:41)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-13604
|
|
|
Person completing record
prsb03-dataelement-11964
|
|
|
|
|
Name
prsb03-dataelement-11965
|
|
|
| Id |
prsb03-dataelement-11965 (2019‑05‑31 15:03:12)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-11966
|
|
|
| Id |
prsb03-dataelement-11966 (2019‑05‑31 15:03:12)
|
| Concept inherits from |
prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-11967
|
|
|
| Id |
prsb03-dataelement-11967 (2019‑05‑31 15:03:12)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-11968
|
|
|
|
|
Organisation
prsb03-dataelement-11969
|
|
|
|
|
Professional identifier
prsb03-dataelement-11970
|
|
|
| Id |
prsb03-dataelement-11970 (2019‑05‑31 15:03:12)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-11971
|
|
|
| Id |
prsb03-dataelement-11971 (2019‑05‑31 15:03:12)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-11972
|
|
|
| Id |
prsb03-dataelement-11972 (2019‑05‑31 15:03:12)
|
| Concept inherits from |
prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
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. |
|
|
Start date of risk
prsb03-dataelement-11973
|
|
|
| Id |
prsb03-dataelement-11973 (2019‑05‑31 15:03:41)
|
| Concept inherits from |
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 |
|
|
|
End date of risk
prsb03-dataelement-11974
|
|
|
| Id |
prsb03-dataelement-11974 (2019‑05‑31 15:04:10)
|
| Concept inherits from |
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 |
|
|
|
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 |
|
|
|
Location
prsb03-dataelement-11975
|
|
|
| Id |
prsb03-dataelement-11975 (2019‑05‑31 15:04:35)
|
| Description |
The location where the other risks were identified. |
| Relationship |
|
|
|
Coded value
prsb03-dataelement-13594
|
|
|
|
|
Free text
prsb03-dataelement-13595
|
|
|
|
|
Performing professional
prsb03-dataelement-11976
|
|
|
| Id |
prsb03-dataelement-11976 (2019‑05‑31 15:05:03)
|
| Description |
The professional who identified the other risks. |
| Relationship |
|
|
|
Name
prsb03-dataelement-11977
|
|
|
| Id |
prsb03-dataelement-11977 (2019‑05‑31 15:05:19)
|
| Concept inherits from |
prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
|
|
Role
prsb03-dataelement-11978
|
|
|
| Id |
prsb03-dataelement-11978 (2019‑05‑31 15:05:19)
|
| Concept inherits from |
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 |
|
|
|
Grade
prsb03-dataelement-11979
|
|
|
| Id |
prsb03-dataelement-11979 (2019‑05‑31 15:05:19)
|
| Concept inherits from |
prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Speciality
prsb03-dataelement-11980
|
|
|
|
|
Professional identifier
prsb03-dataelement-11981
|
|
|
| Id |
prsb03-dataelement-11981 (2019‑05‑31 15:05:19)
|
| Concept inherits from |
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 |
|
|
|
Organisation
prsb03-dataelement-11982
|
|
|
|
|
Contact details
prsb03-dataelement-11983
|
|
|
| Id |
prsb03-dataelement-11983 (2019‑05‑31 15:05:19)
|
| Concept inherits from |
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 |
|
|
|
Person completing record
prsb03-dataelement-11984
|
|
|
|
|
Name
prsb03-dataelement-11985
|
|
|
| Id |
prsb03-dataelement-11985 (2019‑05‑31 15:05:47)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-11986
|
|
|
| Id |
prsb03-dataelement-11986 (2019‑05‑31 15:05:47)
|
| Concept inherits from |
prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-11987
|
|
|
| Id |
prsb03-dataelement-11987 (2019‑05‑31 15:05:47)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-11988
|
|
|
|
|
Organisation
prsb03-dataelement-11989
|
|
|
|
|
Professional identifier
prsb03-dataelement-11990
|
|
|
| Id |
prsb03-dataelement-11990 (2019‑05‑31 15:05:47)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-11991
|
|
|
| Id |
prsb03-dataelement-11991 (2019‑05‑31 15:05:47)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-11992
|
|
|
| Id |
prsb03-dataelement-11992 (2019‑05‑31 15:05:47)
|
| Concept inherits from |
prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
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 |
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 5 times |
| |
This concept is inherited by concept
Start date of risk in dataset prsb03-dataelement-11893
This concept is inherited by concept
Start date of risk in dataset prsb03-dataelement-11913
This concept is inherited by concept
Start date of risk in dataset prsb03-dataelement-11933
This concept is inherited by concept
Start date of risk in dataset prsb03-dataelement-11953
This concept is inherited by concept
Start date of risk in dataset prsb03-dataelement-11973
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 5 times |
| |
This concept is inherited by concept
End date of risk in dataset prsb03-dataelement-11894
This concept is inherited by concept
End date of risk in dataset prsb03-dataelement-11914
This concept is inherited by concept
End date of risk in dataset prsb03-dataelement-11934
This concept is inherited by concept
End date of risk in dataset prsb03-dataelement-11954
This concept is inherited by concept
End date of risk in dataset prsb03-dataelement-11974
|
|
|
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 |
|
|
|
Location
prsb03-dataelement-10180
|
|
|
|
|
Coded value
prsb03-dataelement-13584
|
|
|
|
|
Free text
prsb03-dataelement-13585
|
|
|
|
|
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 |
|
|
|
Name
prsb03-dataelement-13598
|
|
|
| Id |
prsb03-dataelement-13598 (2020‑09‑08 16:02:57)
|
| Concept inherits from |
prsb03-dataelement-11957 (2019‑05‑31 15:02:41)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
|
|
Role
prsb03-dataelement-13599
|
|
|
| Id |
prsb03-dataelement-13599 (2020‑09‑08 16:02:57)
|
| Concept inherits from |
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 |
|
|
|
Grade
prsb03-dataelement-13600
|
|
|
| Id |
prsb03-dataelement-13600 (2020‑09‑08 16:02:57)
|
| Concept inherits from |
prsb03-dataelement-11959 (2019‑05‑31 15:02:41)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Speciality
prsb03-dataelement-13601
|
|
|
|
|
Professional identifier
prsb03-dataelement-13602
|
|
|
| Id |
prsb03-dataelement-13602 (2020‑09‑08 16:02:57)
|
| Concept inherits from |
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 |
|
|
|
Organisation
prsb03-dataelement-13603
|
|
|
|
|
Contact details
prsb03-dataelement-13604
|
|
|
| Id |
prsb03-dataelement-13604 (2020‑09‑08 16:02:57)
|
| Concept inherits from |
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 |
|
|
|
Person completing record
prsb03-dataelement-13605
|
|
|
| Id |
prsb03-dataelement-13605 (2020‑09‑08 16:04:28)
|
| Concept inherits from |
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 |
|
|
|
Name
prsb03-dataelement-13606
|
|
|
| Id |
prsb03-dataelement-13606 (2020‑09‑08 16:05:09)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-13607
|
|
|
| Id |
prsb03-dataelement-13607 (2020‑09‑08 16:05:09)
|
| Concept inherits from |
prsb03-dataelement-13037 (2020‑04‑28 19:33:40)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-13608
|
|
|
| Id |
prsb03-dataelement-13608 (2020‑09‑08 16:05:09)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-13609
|
|
|
|
|
Organisation
prsb03-dataelement-13610
|
|
|
|
|
Professional identifier
prsb03-dataelement-13611
|
|
|
| Id |
prsb03-dataelement-13611 (2020‑09‑08 16:05:09)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-13612
|
|
|
| Id |
prsb03-dataelement-13612 (2020‑09‑08 16:05:09)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-13613
|
|
|
| Id |
prsb03-dataelement-13613 (2020‑09‑08 16:05:09)
|
| Concept inherits from |
prsb03-dataelement-13043 (2020‑04‑28 19:33:40)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
Person completing record
prsb03-dataelement-10959
|
|
|
| Id |
prsb03-dataelement-10959 (2019‑05‑18 21:13:52) 0.1
|
| Concept inherits from |
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 |
|
|
|
Other risk behaviours
prsb03-dataelement-10752
|
|
|
|
|
Factors affecting risk
prsb03-dataelement-10753
|
|
|
|
|
Allergies and adverse reactions
prsb03-dataelement-282
|
|
|
|
|
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.
|
|
|
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) |
| FHIR |
AllergyIntolerance.type |
|
| Rationale |
AllergyIntolerance.type |
| Operationalization |
FHIR value set :-
Allergy, Intolerance
|
| Value Domain |
|
|
|
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”
|
| FHIR |
AllergyIntolerance.code |
|
|
|
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 |
|
|
|
Free text
prsb03-dataelement-13442
|
|
|
|
|
Reaction details cluster
prsb03-dataelement-10658
|
|
|
|
|
Date
prsb03-dataelement-10190
|
|
|
| Id |
prsb03-dataelement-10190 (2018‑10‑31)
|
| Description |
The date that the reaction was identified. |
|
|
| Rationale |
Allergyintolerance.asserteddate |
| Operationalization |
Date and time |
| Value Domain |
|
| Property |
| Timestamp precision |
| at least day, month and year, hour and minute |
|
|
|
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.
|
|
|
Coded value
prsb03-dataelement-13439
|
|
|
|
|
Free text
prsb03-dataelement-13440
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
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.
|
|
|
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 |
|
|
|
Free text
prsb03-dataelement-13555
|
|
|
|
|
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.
|
| FHIR |
AllergyIntolerance.reaction.manifestation AllergyIntolerance.reaction.description |
|
|
|
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 |
|
|
|
Free text
prsb03-dataelement-13557
|
|
|
|
|
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 |
|
|
|
Severity
prsb03-dataelement-10184
|
|
|
| Id |
prsb03-dataelement-10184 (2018‑10‑31)
|
| Description |
A description of the severity of the reaction. |
| FHIR |
AllergyIntolerance.reaction.severity |
|
|
|
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 |
|
|
|
Free text
prsb03-dataelement-13559
|
|
|
|
|
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.
|
| FHIR |
AllergyIntolerance.verificationStatus |
|
|
|
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 |
|
|
|
Free text
prsb03-dataelement-13561
|
|
|
|
|
Route of exposure
prsb03-dataelement-13856
|
|
|
|
|
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 |
|
|
|
Free text
prsb03-dataelement-13858
|
|
|
|
|
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 |
|
|
|
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
|
| FHIR |
AllergyIntolerance.extension.evidence |
|
| Rationale |
AllergyIntolerance.extension.evidence |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
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)
|
| FHIR |
AllergyIntolerance.onset[x] |
|
| Rationale |
AllergyIntolerance.onset |
| Operationalization |
Date and time |
| Value Domain |
|
| Property |
| Timestamp precision |
| at least year |
|
|
|
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 |
|
|
|
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 |
|
|
|
Probability of recurrence
prsb03-dataelement-10191
|
|
|
| Id |
prsb03-dataelement-10191 (2018‑10‑31) 0.1
|
| Description |
Probability of the reaction (allergic, adverse, intolerant) occurring. |
| FHIR |
AllergyIntolerance.extension.ProbabilityOfRecurrence |
|
| Rationale |
AllergyIntolerance.extension.ProbabilityOfRecurrence |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Performing professional
prsb03-dataelement-12010
|
|
|
| Id |
prsb03-dataelement-12010 (2019‑05‑31 15:23:59)
|
| Description |
The professional who identified the reaction. |
| Relationship |
|
|
|
Name
prsb03-dataelement-12011
|
|
|
| Id |
prsb03-dataelement-12011 (2019‑05‑31 15:24:24)
|
| Concept inherits from |
prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
|
|
Role
prsb03-dataelement-12012
|
|
|
| Id |
prsb03-dataelement-12012 (2019‑05‑31 15:24:24)
|
| Concept inherits from |
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 |
|
|
|
Grade
prsb03-dataelement-12013
|
|
|
| Id |
prsb03-dataelement-12013 (2019‑05‑31 15:24:24)
|
| Concept inherits from |
prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Speciality
prsb03-dataelement-12014
|
|
|
|
|
Professional identifier
prsb03-dataelement-12015
|
|
|
| Id |
prsb03-dataelement-12015 (2019‑05‑31 15:24:24)
|
| Concept inherits from |
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 |
|
|
|
Organisation
prsb03-dataelement-12016
|
|
|
|
|
Contact details
prsb03-dataelement-12017
|
|
|
| Id |
prsb03-dataelement-12017 (2019‑05‑31 15:24:24)
|
| Concept inherits from |
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 |
|
|
|
Person completing record
prsb03-dataelement-12018
|
|
|
|
|
Name
prsb03-dataelement-12019
|
|
|
| Id |
prsb03-dataelement-12019 (2019‑05‑31 15:24:56)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-12020
|
|
|
| Id |
prsb03-dataelement-12020 (2019‑05‑31 15:24:56)
|
| Concept inherits from |
prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-12021
|
|
|
| Id |
prsb03-dataelement-12021 (2019‑05‑31 15:24:56)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-12022
|
|
|
|
|
Organisation
prsb03-dataelement-12023
|
|
|
|
|
Professional identifier
prsb03-dataelement-12024
|
|
|
| Id |
prsb03-dataelement-12024 (2019‑05‑31 15:24:56)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-12025
|
|
|
| Id |
prsb03-dataelement-12025 (2019‑05‑31 15:24:56)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-12026
|
|
|
| Id |
prsb03-dataelement-12026 (2019‑05‑31 15:24:56)
|
| Concept inherits from |
prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
Person completing record
prsb03-dataelement-10960
|
|
|
| Id |
prsb03-dataelement-10960 (2019‑05‑18 21:15:23)
|
| Concept inherits from |
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 |
|
|
|
Medications and medical devices
prsb03-dataelement-636
|
|
|
| Id |
prsb03-dataelement-636 (2018‑10‑31)
|
| Description |
Medications and medical devices |
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
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 |
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Medication name
prsb03-dataelement-12484
|
|
|
| Id |
prsb03-dataelement-12484 (2019‑07‑03 12:27:06)
|
| Concept inherits from |
prsb03-dataelement-10536 (2018‑10‑31)
|
| Description |
May be generic name or brand name. |
| 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)
|
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Medication name in dataset prsb03-dataelement-12528
|
|
|
Coded value
prsb03-dataelement-13663
|
|
|
| Id |
prsb03-dataelement-13663 (2020‑09‑08 21:49:56)
|
| Concept inherits from |
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 |
|
|
|
Free text
prsb03-dataelement-13664
|
|
|
|
|
Route
prsb03-dataelement-12485
|
|
|
| Id |
prsb03-dataelement-12485 (2019‑07‑03 12:28:40)
|
| Concept inherits from |
prsb03-dataelement-10538 (2018‑10‑31)
|
| Description |
The route by which the medication is administered e.g. oral, IM, IV |
| FHIR |
MedicationStatement.dosage.route |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Route in dataset prsb03-dataelement-12529
|
|
|
Coded value
prsb03-dataelement-13661
|
|
|
| Id |
prsb03-dataelement-13661 (2020‑09‑08 21:47:04)
|
| Concept inherits from |
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 |
|
|
|
Free text
prsb03-dataelement-13662
|
|
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Dose administered in dataset prsb03-dataelement-12530
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
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.
|
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
|
|
|
Medication item cluster
prsb03-dataelement-10664
|
|
|
| Id |
prsb03-dataelement-10664 (2018‑11‑13 16:25:51)
|
| Description |
Medication item cluster |
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 3 times |
| |
This concept is inherited by concept
Date in dataset prsb03-dataelement-12534
This concept is inherited by concept
Date in dataset prsb03-dataelement-13112
This concept is inherited by concept
Date in dataset prsb03-dataelement-12650
|
|
|
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. |
Used by
|
0 transactions, 0 templates, inherited 3 times |
| |
This concept is inherited by concept
Location in dataset prsb03-dataelement-12535
This concept is inherited by concept
Location in dataset prsb03-dataelement-13113
This concept is inherited by concept
Location in dataset prsb03-dataelement-12651
|
|
|
Coded value
prsb03-dataelement-13620
|
|
|
|
|
Free text
prsb03-dataelement-13621
|
|
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 3 times |
| |
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 3 times |
| |
|
|
|
Name
prsb03-dataelement-12003
|
|
|
| Id |
prsb03-dataelement-12003 (2019‑05‑31 15:12:48)
|
| Concept inherits from |
prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited 3 times |
| |
This concept is inherited by concept
Name in dataset prsb03-dataelement-12538
This concept is inherited by concept
Name in dataset prsb03-dataelement-13116
This concept is inherited by concept
Name in dataset prsb03-dataelement-12654
|
|
|
Role
prsb03-dataelement-12004
|
|
|
| Id |
prsb03-dataelement-12004 (2019‑05‑31 15:12:48)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited 3 times |
| |
This concept is inherited by concept
Role in dataset prsb03-dataelement-12539
This concept is inherited by concept
Role in dataset prsb03-dataelement-13117
This concept is inherited by concept
Role in dataset prsb03-dataelement-12655
|
|
|
Grade
prsb03-dataelement-12005
|
|
|
| Id |
prsb03-dataelement-12005 (2019‑05‑31 15:12:48)
|
| Concept inherits from |
prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited 3 times |
| |
This concept is inherited by concept
Grade in dataset prsb03-dataelement-12540
This concept is inherited by concept
Grade in dataset prsb03-dataelement-13118
This concept is inherited by concept
Grade in dataset prsb03-dataelement-12656
|
|
|
Speciality
prsb03-dataelement-12006
|
|
|
| Id |
prsb03-dataelement-12006 (2019‑05‑31 15:12:48)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited 3 times |
| |
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-12541
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-13119
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-12657
|
|
|
Professional identifier
prsb03-dataelement-12007
|
|
|
| Id |
prsb03-dataelement-12007 (2019‑05‑31 15:12:48)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited 3 times |
| |
|
|
|
Organisation
prsb03-dataelement-12008
|
|
|
| Id |
prsb03-dataelement-12008 (2019‑05‑31 15:12:48)
|
| Concept inherits from |
prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
|
| Description |
The name of the organisation the professional works for. |
Used by
|
0 transactions, 0 templates, inherited 3 times |
| |
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-12543
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-13121
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-12659
|
|
|
Contact details
prsb03-dataelement-12009
|
|
|
| Id |
prsb03-dataelement-12009 (2019‑05‑31 15:12:48)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited 3 times |
| |
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-12544
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-13122
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-12660
|
|
|
Medication name
prsb03-dataelement-10536
|
|
|
| Id |
prsb03-dataelement-10536 (2018‑10‑31)
|
| Description |
May be generic name or brand name. |
| 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)
|
|
Used by
|
0 transactions, 0 templates, inherited 5 times |
| |
This concept is inherited by concept
Medication name in dataset prsb03-dataelement-12545
This concept is inherited by concept
Medication name in dataset prsb03-dataelement-12484
This concept is inherited by concept
Medication name in dataset prsb03-dataelement-13200
This concept is inherited by concept
Medication name in dataset prsb03-dataelement-13123
This concept is inherited by concept
Medication name in dataset prsb03-dataelement-12661
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Coded value in dataset prsb03-dataelement-13663
|
|
|
Free text
prsb03-dataelement-13623
|
|
|
| Id |
prsb03-dataelement-13623 (2020‑09‑08 19:17:39)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Free text in dataset prsb03-dataelement-13664
|
|
|
Form
prsb03-dataelement-10537
|
|
|
| Id |
prsb03-dataelement-10537 (2018‑10‑31)
|
| Description |
The form of the medication e.g. capsule, drops, tablet, lotion etc. |
| 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
|
|
Used by
|
0 transactions, 0 templates, inherited 4 times |
| |
This concept is inherited by concept
Form in dataset prsb03-dataelement-12546
This concept is inherited by concept
Form in dataset prsb03-dataelement-13202
This concept is inherited by concept
Form in dataset prsb03-dataelement-13124
This concept is inherited by concept
Form in dataset prsb03-dataelement-12662
|
|
|
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 |
|
|
|
Free text
prsb03-dataelement-13625
|
|
|
|
|
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
|
| FHIR |
MedicationStatement.quantityDispensed (Amount of medication to supply per dispense)
quantity (as a valueQuantity) - Mandatory quantityText (as a valueString) - Mandatory
|
|
| Operationalization |
Free text |
Used by
|
0 transactions, 0 templates, inherited 3 times |
| |
This concept is inherited by concept
Quantity supplied in dataset prsb03-dataelement-12547
This concept is inherited by concept
Quantity supplied in dataset prsb03-dataelement-13125
This concept is inherited by concept
Quantity supplied in dataset prsb03-dataelement-12663
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
| FHIR |
MedicationStatement.dosage.route |
|
Used by
|
0 transactions, 0 templates, inherited 5 times |
| |
This concept is inherited by concept
Route in dataset prsb03-dataelement-12548
This concept is inherited by concept
Route in dataset prsb03-dataelement-12485
This concept is inherited by concept
Route in dataset prsb03-dataelement-13203
This concept is inherited by concept
Route in dataset prsb03-dataelement-13126
This concept is inherited by concept
Route in dataset prsb03-dataelement-12664
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Coded value in dataset prsb03-dataelement-13661
|
|
|
Free text
prsb03-dataelement-13656
|
|
|
| Id |
prsb03-dataelement-13656 (2020‑09‑08 20:31:40)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Free text in dataset prsb03-dataelement-13662
|
|
|
Site
prsb03-dataelement-10540
|
|
|
| Id |
prsb03-dataelement-10540 (2018‑10‑31)
|
| Description |
The anatomical site at which the medication is to be administered. |
| FHIR |
MedicationStatement.dosage.site |
|
Used by
|
0 transactions, 0 templates, inherited 4 times |
| |
This concept is inherited by concept
Site in dataset prsb03-dataelement-12549
This concept is inherited by concept
Site in dataset prsb03-dataelement-13871
This concept is inherited by concept
Site in dataset prsb03-dataelement-13127
This concept is inherited by concept
Site in dataset prsb03-dataelement-12665
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
This concept is inherited by concept
Coded value in dataset prsb03-dataelement-13830
This concept is inherited by concept
Coded value in dataset prsb03-dataelement-13872
|
|
|
Free text
prsb03-dataelement-13658
|
|
|
| Id |
prsb03-dataelement-13658 (2020‑09‑08 20:35:42)
|
| Concept inherits from |
prsb03-dataelement-13229 (2020‑07‑15 19:30:33)
|
| Description |
Amount of vaccine administered. |
| Relationship |
|
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
This concept is inherited by concept
Free text in dataset prsb03-dataelement-13831
This concept is inherited by concept
Free text in dataset prsb03-dataelement-13873
|
|
|
Method
prsb03-dataelement-10541
|
|
|
| Id |
prsb03-dataelement-10541 (2018‑10‑31)
|
| Description |
The technique or method by which the medication is to be administered. |
| FHIR |
MedicationStatement.dosage.method |
|
Used by
|
0 transactions, 0 templates, inherited 3 times |
| |
This concept is inherited by concept
Method in dataset prsb03-dataelement-12550
This concept is inherited by concept
Method in dataset prsb03-dataelement-13128
This concept is inherited by concept
Method in dataset prsb03-dataelement-12666
|
|
|
Coded value
prsb03-dataelement-13845
|
|
|
|
|
Free text
prsb03-dataelement-13846
|
|
|
|
|
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 |
|
|
|
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 |
|
|
Batch number
prsb03-dataelement-13789
|
|
|
|
|
Coded value
prsb03-dataelement-13790
|
|
|
| Id |
prsb03-dataelement-13790 (2020‑10‑22 18:26:28)
|
| Concept inherits from |
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 |
|
|
|
Free text
prsb03-dataelement-13791
|
|
|
|
|
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 |
|
|
|
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”.
|
| FHIR |
MedicationStatement.dosage.text |
|
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited 4 times |
| |
|
|
|
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". |
| FHIR |
MedicationStatement.dosage.text |
|
| Operationalization |
Free text |
| Value Domain |
|
Used by
|
0 transactions, 0 templates, inherited 4 times |
| |
|
|
|
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".
|
| FHIR |
MedicationStatement.dosage.timing [a complex data type that holds lots of timing formats] |
|
| Operationalization |
Free text |
| Value Domain |
|
Used by
|
0 transactions, 0 templates, inherited 4 times |
| |
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 3 times |
| |
|
|
|
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.
|
Used by
|
0 transactions, 0 templates, inherited 3 times |
| |
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 3 times |
| |
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 3 times |
| |
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 3 times |
| |
|
|
|
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.
|
| 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 |
|
Used by
|
0 transactions, 0 templates, inherited 3 times |
| |
|
|
|
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.
|
| 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 |
|
Used by
|
0 transactions, 0 templates, inherited 3 times |
| |
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 3 times |
| |
This concept is inherited by concept
Request for advice in dataset prsb03-dataelement-12561
This concept is inherited by concept
Request for advice in dataset prsb03-dataelement-13139
This concept is inherited by concept
Request for advice in dataset prsb03-dataelement-12677
|
|
|
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 |
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 3 times |
| |
|
|
|
Course details cluster
prsb03-dataelement-10561
|
|
|
| Id |
prsb03-dataelement-10561 (2018‑10‑31)
|
| Description |
Details of the overall course of medication. |
Used by
|
0 transactions, 0 templates, inherited 3 times |
| |
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 3 times |
| |
This concept is inherited by concept
Course status in dataset prsb03-dataelement-12564
This concept is inherited by concept
Course status in dataset prsb03-dataelement-13142
This concept is inherited by concept
Course status in dataset prsb03-dataelement-12680
|
|
|
Indication
prsb03-dataelement-10546
|
|
|
| Id |
prsb03-dataelement-10546 (2018‑10‑31)
|
| Description |
Reason for medication being prescribed, where known. |
| FHIR |
MedicationStatement.reasonCode |
|
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited 3 times |
| |
This concept is inherited by concept
Indication in dataset prsb03-dataelement-12565
This concept is inherited by concept
Indication in dataset prsb03-dataelement-13143
This concept is inherited by concept
Indication in dataset prsb03-dataelement-12681
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 3 times |
| |
This concept is inherited by concept
Start date/time in dataset prsb03-dataelement-12566
This concept is inherited by concept
Start date/time in dataset prsb03-dataelement-13144
This concept is inherited by concept
Start date/time in dataset prsb03-dataelement-12682
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 3 times |
| |
This concept is inherited by concept
End date/time in dataset prsb03-dataelement-12567
This concept is inherited by concept
End date/time in dataset prsb03-dataelement-13145
This concept is inherited by concept
End date/time in dataset prsb03-dataelement-12683
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 3 times |
| |
|
|
|
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
|
| FHIR |
[JH] This will be dropped from the PRSB information model, as conflicts with description
above
|
|
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited 3 times |
| |
|
|
|
Medication change summary cluster
prsb03-dataelement-10568
|
|
|
| Id |
prsb03-dataelement-10568 (2018‑10‑31)
|
| Description |
Records the changes made to medication. |
Used by
|
0 transactions, 0 templates, inherited 3 times |
| |
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 3 times |
| |
This concept is inherited by concept
Status in dataset prsb03-dataelement-12571
This concept is inherited by concept
Status in dataset prsb03-dataelement-13149
This concept is inherited by concept
Status in dataset prsb03-dataelement-12687
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 3 times |
| |
This concept is inherited by concept
Indication in dataset prsb03-dataelement-12572
This concept is inherited by concept
Indication in dataset prsb03-dataelement-13150
This concept is inherited by concept
Indication in dataset prsb03-dataelement-12688
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 3 times |
| |
This concept is inherited by concept
Date of change in dataset prsb03-dataelement-12573
This concept is inherited by concept
Date of change in dataset prsb03-dataelement-13151
This concept is inherited by concept
Date of change in dataset prsb03-dataelement-12689
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 3 times |
| |
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 3 times |
| |
|
|
|
Anticipatory medicines/equipment
prsb03-dataelement-14023
|
|
|
| Id |
prsb03-dataelement-14023 (2021‑02‑15 17:36:45)
|
| Concept inherits from |
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 |
|
|
|
Person completing record
prsb03-dataelement-11993
|
|
|
| Id |
prsb03-dataelement-11993 (2019‑05‑31 15:11:27)
|
| Concept inherits from |
prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
|
| Description |
Details of the person completing the record. |
| Relationship |
|
Used by
|
0 transactions, 0 templates, inherited 3 times |
| |
|
|
|
Name
prsb03-dataelement-11994
|
|
|
| Id |
prsb03-dataelement-11994 (2019‑05‑31 15:12:02)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited 3 times |
| |
This concept is inherited by concept
Name in dataset prsb03-dataelement-12577
This concept is inherited by concept
Name in dataset prsb03-dataelement-13155
This concept is inherited by concept
Name in dataset prsb03-dataelement-12693
|
|
|
Role
prsb03-dataelement-11995
|
|
|
| Id |
prsb03-dataelement-11995 (2019‑05‑31 15:12:02)
|
| Concept inherits from |
prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
Used by
|
0 transactions, 0 templates, inherited 3 times |
| |
This concept is inherited by concept
Role in dataset prsb03-dataelement-12578
This concept is inherited by concept
Role in dataset prsb03-dataelement-13156
This concept is inherited by concept
Role in dataset prsb03-dataelement-12694
|
|
|
Grade
prsb03-dataelement-11996
|
|
|
| Id |
prsb03-dataelement-11996 (2019‑05‑31 15:12:02)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited 3 times |
| |
This concept is inherited by concept
Grade in dataset prsb03-dataelement-12579
This concept is inherited by concept
Grade in dataset prsb03-dataelement-13157
This concept is inherited by concept
Grade in dataset prsb03-dataelement-12695
|
|
|
Specialty
prsb03-dataelement-11997
|
|
|
| Id |
prsb03-dataelement-11997 (2019‑05‑31 15:12:02)
|
| Concept inherits from |
prsb03-dataelement-11293 (2019‑05‑30 12:25:39)
|
| Description |
The main specialty of the person completing the record. |
| FHIR |
PractitionerRole.specialty |
|
| Relationship |
|
| Rationale |
PractitionerRole.speciality |
| Operationalization |
NHS data dictionary :-
Activity treatment function code
|
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited 3 times |
| |
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-12580
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-13158
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-12696
|
|
|
Organisation
prsb03-dataelement-11998
|
|
|
| Id |
prsb03-dataelement-11998 (2019‑05‑31 15:12:02)
|
| Concept inherits from |
prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
|
| Description |
The organisation the person completing the record works for. |
| Relationship |
|
Used by
|
0 transactions, 0 templates, inherited 3 times |
| |
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-12581
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-13159
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-12697
|
|
|
Professional identifier
prsb03-dataelement-11999
|
|
|
| Id |
prsb03-dataelement-11999 (2019‑05‑31 15:12:02)
|
| Concept inherits from |
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.
|
| 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 |
|
Used by
|
0 transactions, 0 templates, inherited 3 times |
| |
|
|
|
Date completed
prsb03-dataelement-12000
|
|
|
| Id |
prsb03-dataelement-12000 (2019‑05‑31 15:12:02)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited 3 times |
| |
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-12583
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-13161
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-12699
|
|
|
Contact details
prsb03-dataelement-12001
|
|
|
| Id |
prsb03-dataelement-12001 (2019‑05‑31 15:12:02)
|
| Concept inherits from |
prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited 3 times |
| |
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-12584
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-13162
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-12700
|
|
|
Medical devices entry
prsb03-dataelement-10583
|
|
|
| Id |
prsb03-dataelement-10583 (2018‑10‑31)
|
| Description |
Medical devices |
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
This concept is inherited by concept
Medical device in dataset prsb03-dataelement-12594
This concept is inherited by concept
Medical device in dataset prsb03-dataelement-13172
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
This concept is inherited by concept
Comments in dataset prsb03-dataelement-12595
This concept is inherited by concept
Comments in dataset prsb03-dataelement-13173
|
|
|
Medication discontinued entry
prsb03-dataelement-10576
|
|
|
| Id |
prsb03-dataelement-10576 (2018‑10‑31)
|
| Description |
Medication discontinued entry |
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
|
|
|
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 |
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
|
|
|
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 |
|
|
|
Free text
prsb03-dataelement-13660
|
|
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
This concept is inherited by concept
Status in dataset prsb03-dataelement-12587
This concept is inherited by concept
Status in dataset prsb03-dataelement-13165
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
This concept is inherited by concept
Status in dataset prsb03-dataelement-12588
This concept is inherited by concept
Status in dataset prsb03-dataelement-13166
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 3 times |
| |
This concept is inherited by concept
Indication in dataset prsb03-dataelement-12589
This concept is inherited by concept
Indication in dataset prsb03-dataelement-13167
This concept is inherited by concept
Indication in dataset prsb03-dataelement-12705
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
This concept is inherited by concept
Date of change in dataset prsb03-dataelement-12590
This concept is inherited by concept
Date of change in dataset prsb03-dataelement-13168
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
This concept is inherited by concept
Comment in dataset prsb03-dataelement-12592
This concept is inherited by concept
Comment in dataset prsb03-dataelement-13170
|
|
|
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.
|
|
|
Medication name
prsb03-dataelement-13200
|
|
|
| Id |
prsb03-dataelement-13200 (2020‑06‑24 17:45:11) 0.1
|
| Concept inherits from |
prsb03-dataelement-10536 (2018‑10‑31)
|
| Description |
May be generic name or brand name. |
| 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)
|
|
|
|
Indication
prsb03-dataelement-13201
|
|
|
| Id |
prsb03-dataelement-13201 (2020‑06‑24 17:46:45) 0.1
|
| Description |
Reason for medication being taken, where known. |
| 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 |
|
|
|
Form
prsb03-dataelement-13202
|
|
|
| Id |
prsb03-dataelement-13202 (2020‑06‑24 17:49:30) 0.1
|
| Concept inherits from |
prsb03-dataelement-10537 (2018‑10‑31)
|
| Description |
The form of the medication e.g. capsule, drops, tablet, lotion etc. |
| 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
|
|
|
|
Route
prsb03-dataelement-13203
|
|
|
|
|
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. |
| 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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Site in dataset prsb03-dataelement-13828
|
|
|
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. |
| FHIR |
MedicationStatement.dosage.method |
|
| Relationship |
|
| Operationalization |
Free text |
| Value Domain |
|
|
|
Dose directions description
prsb03-dataelement-13206
|
|
|
| Id |
prsb03-dataelement-13206 (2020‑06‑24 17:54:29) 0.1
|
| Concept inherits from |
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”.
|
| FHIR |
MedicationStatement.dosage.text |
|
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Dose amount description
prsb03-dataelement-13207
|
|
|
| Id |
prsb03-dataelement-13207 (2020‑06‑24 17:55:24) 0.1
|
| Concept inherits from |
prsb03-dataelement-10542 (2018‑10‑31)
|
| Description |
A description of the medication single dose amount e.g. "30 mg" or "2 tabs". |
| FHIR |
MedicationStatement.dosage.text |
|
| Operationalization |
Free text |
| Value Domain |
|
|
|
Dose timing description
prsb03-dataelement-13208
|
|
|
| Id |
prsb03-dataelement-13208 (2020‑06‑24 17:56:17) 0.1
|
| Concept inherits from |
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".
|
| FHIR |
MedicationStatement.dosage.timing [a complex data type that holds lots of timing formats] |
|
| Operationalization |
Free text |
| Value Domain |
|
|
|
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 |
|
|
|
Name
prsb03-dataelement-13211
|
|
|
| Id |
prsb03-dataelement-13211 (2020‑06‑24 18:01:03) 0.1
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-13212
|
|
|
| Id |
prsb03-dataelement-13212 (2020‑06‑24 18:01:03) 0.1
|
| Concept inherits from |
prsb03-dataelement-13193 (2020‑06‑24 17:27:59)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-13213
|
|
|
| Id |
prsb03-dataelement-13213 (2020‑06‑24 18:01:03) 0.1
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-13214
|
|
|
|
|
Organisation
prsb03-dataelement-13215
|
|
|
|
|
Professional identifier
prsb03-dataelement-13216
|
|
|
| Id |
prsb03-dataelement-13216 (2020‑06‑24 18:01:03) 0.1
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-13217
|
|
|
| Id |
prsb03-dataelement-13217 (2020‑06‑24 18:01:03) 0.1
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-13218
|
|
|
| Id |
prsb03-dataelement-13218 (2020‑06‑24 18:01:03) 0.1
|
| Concept inherits from |
prsb03-dataelement-13199 (2020‑06‑24 17:27:59)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
Person completing record
prsb03-dataelement-13209
|
|
|
| Id |
prsb03-dataelement-13209 (2020‑06‑24 17:58:16) 0.1
|
| Concept inherits from |
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 |
|
|
|
Medication item entry
prsb03-dataelement-13110
|
|
|
| Id |
prsb03-dataelement-13110 (2020‑06‑24 16:05:21) 0.1
|
| Concept inherits from |
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.
|
|
|
Medication item cluster
prsb03-dataelement-13111
|
|
|
|
|
Date
prsb03-dataelement-13112
|
|
|
| Id |
prsb03-dataelement-13112 (2020‑06‑24 16:06:14) 0.1
|
| Concept inherits from |
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 |
|
|
|
Location
prsb03-dataelement-13113
|
|
|
|
|
Performing professional
prsb03-dataelement-13114
|
|
|
|
|
Performing professional
prsb03-dataelement-13115
|
|
|
|
|
Name
prsb03-dataelement-13116
|
|
|
| Id |
prsb03-dataelement-13116 (2020‑06‑24 16:06:14) 0.1
|
| Concept inherits from |
prsb03-dataelement-12003 (2019‑05‑31 15:12:48)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
|
|
Role
prsb03-dataelement-13117
|
|
|
| Id |
prsb03-dataelement-13117 (2020‑06‑24 16:06:14) 0.1
|
| Concept inherits from |
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 |
|
|
|
Grade
prsb03-dataelement-13118
|
|
|
| Id |
prsb03-dataelement-13118 (2020‑06‑24 16:06:14) 0.1
|
| Concept inherits from |
prsb03-dataelement-12005 (2019‑05‑31 15:12:48)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Speciality
prsb03-dataelement-13119
|
|
|
|
|
Professional identifier
prsb03-dataelement-13120
|
|
|
| Id |
prsb03-dataelement-13120 (2020‑06‑24 16:06:14) 0.1
|
| Concept inherits from |
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 |
|
|
|
Organisation
prsb03-dataelement-13121
|
|
|
|
|
Contact details
prsb03-dataelement-13122
|
|
|
| Id |
prsb03-dataelement-13122 (2020‑06‑24 16:06:14) 0.1
|
| Concept inherits from |
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 |
|
|
|
Medication name
prsb03-dataelement-13123
|
|
|
| Id |
prsb03-dataelement-13123 (2020‑06‑24 16:06:14) 0.1
|
| Concept inherits from |
prsb03-dataelement-10536 (2018‑10‑31)
|
| Description |
May be generic name or brand name. |
| 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)
|
|
|
|
Form
prsb03-dataelement-13124
|
|
|
| Id |
prsb03-dataelement-13124 (2020‑06‑24 16:06:14) 0.1
|
| Concept inherits from |
prsb03-dataelement-10537 (2018‑10‑31)
|
| Description |
The form of the medication e.g. capsule, drops, tablet, lotion etc. |
| 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
|
|
|
|
Quantity supplied
prsb03-dataelement-13125
|
|
|
| Id |
prsb03-dataelement-13125 (2020‑06‑24 16:06:14) 0.1
|
| Concept inherits from |
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
|
| FHIR |
MedicationStatement.quantityDispensed (Amount of medication to supply per dispense)
quantity (as a valueQuantity) - Mandatory quantityText (as a valueString) - Mandatory
|
|
| Operationalization |
Free text |
|
|
Route
prsb03-dataelement-13126
|
|
|
|
|
Site
prsb03-dataelement-13127
|
|
|
|
|
Method
prsb03-dataelement-13128
|
|
|
|
|
Dose directions description
prsb03-dataelement-13129
|
|
|
| Id |
prsb03-dataelement-13129 (2020‑06‑24 16:06:14) 0.1
|
| Concept inherits from |
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”.
|
| FHIR |
MedicationStatement.dosage.text |
|
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Dose amount description
prsb03-dataelement-13130
|
|
|
| Id |
prsb03-dataelement-13130 (2020‑06‑24 16:06:14) 0.1
|
| Concept inherits from |
prsb03-dataelement-10542 (2018‑10‑31)
|
| Description |
A description of the medication single dose amount e.g. "30 mg" or "2 tabs". |
| FHIR |
MedicationStatement.dosage.text |
|
| Operationalization |
Free text |
| Value Domain |
|
|
|
Dose timing description
prsb03-dataelement-13131
|
|
|
| Id |
prsb03-dataelement-13131 (2020‑06‑24 16:06:14) 0.1
|
| Concept inherits from |
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".
|
| FHIR |
MedicationStatement.dosage.timing [a complex data type that holds lots of timing formats] |
|
| Operationalization |
Free text |
| Value Domain |
|
|
|
Parsable dose directions
prsb03-dataelement-13132
|
|
|
| Id |
prsb03-dataelement-13132 (2020‑06‑24 16:06:14) 0.1
|
| Concept inherits from |
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 |
|
|
|
Structured dose direction cluster
prsb03-dataelement-13133
|
|
|
| Id |
prsb03-dataelement-13133 (2020‑06‑24 16:06:14) 0.1
|
| Concept inherits from |
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.
|
|
|
Structured dose direction
prsb03-dataelement-13134
|
|
|
|
|
Structured dose amount
prsb03-dataelement-13135
|
|
|
|
|
Structured dose timing
prsb03-dataelement-13136
|
|
|
|
|
Dose direction duration
prsb03-dataelement-13137
|
|
|
| Id |
prsb03-dataelement-13137 (2020‑06‑24 16:06:14) 0.1
|
| Concept inherits from |
prsb03-dataelement-10548 (2018‑10‑31)
|
| Description |
Recommendation of the time period for which the medication should be continued, including
direction not to discontinue.
|
| 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 |
|
|
|
Additional instructions
prsb03-dataelement-13138
|
|
|
| Id |
prsb03-dataelement-13138 (2020‑06‑24 16:06:14) 0.1
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Request for advice
prsb03-dataelement-13139
|
|
|
|
|
Person completing record
prsb03-dataelement-13140
|
|
|
| Id |
prsb03-dataelement-13140 (2020‑06‑24 16:06:14) 0.1
|
| Concept inherits from |
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 |
|
|
|
Course details cluster
prsb03-dataelement-13141
|
|
|
|
|
Course status
prsb03-dataelement-13142
|
|
|
|
|
Indication
prsb03-dataelement-13143
|
|
|
| Id |
prsb03-dataelement-13143 (2020‑06‑24 16:06:14) 0.1
|
| Concept inherits from |
prsb03-dataelement-10546 (2018‑10‑31)
|
| Description |
Reason for medication being prescribed, where known. |
| FHIR |
MedicationStatement.reasonCode |
|
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Start date/time
prsb03-dataelement-13144
|
|
|
| Id |
prsb03-dataelement-13144 (2020‑06‑24 16:06:14) 0.1
|
| Concept inherits from |
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 |
|
|
|
End date/time
prsb03-dataelement-13145
|
|
|
| Id |
prsb03-dataelement-13145 (2020‑06‑24 16:06:14) 0.1
|
| Concept inherits from |
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 |
|
|
|
Link to indication record
prsb03-dataelement-13146
|
|
|
| Id |
prsb03-dataelement-13146 (2020‑06‑24 16:06:14) 0.1
|
| Concept inherits from |
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 |
|
|
|
Comment/recommendation
prsb03-dataelement-13147
|
|
|
| Id |
prsb03-dataelement-13147 (2020‑06‑24 16:06:14) 0.1
|
| Concept inherits from |
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
|
| FHIR |
[JH] This will be dropped from the PRSB information model, as conflicts with description
above
|
|
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Medication change summary cluster
prsb03-dataelement-13148
|
|
|
|
|
Status
prsb03-dataelement-13149
|
|
|
|
|
Indication
prsb03-dataelement-13150
|
|
|
| Id |
prsb03-dataelement-13150 (2020‑06‑24 16:06:14) 0.1
|
| Concept inherits from |
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 |
|
|
|
Date of change
prsb03-dataelement-13151
|
|
|
| Id |
prsb03-dataelement-13151 (2020‑06‑24 16:06:14) 0.1
|
| Concept inherits from |
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 |
|
|
|
Description of amendment
prsb03-dataelement-13152
|
|
|
| Id |
prsb03-dataelement-13152 (2020‑06‑24 16:06:14) 0.1
|
| Concept inherits from |
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 |
|
|
|
Total dose daily quantity
prsb03-dataelement-13153
|
|
|
| Id |
prsb03-dataelement-13153 (2020‑06‑24 16:06:14) 0.1
|
| Concept inherits from |
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 |
|
|
|
Person completing record
prsb03-dataelement-13154
|
|
|
|
|
Name
prsb03-dataelement-13155
|
|
|
| Id |
prsb03-dataelement-13155 (2020‑06‑24 16:06:14) 0.1
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-13156
|
|
|
| Id |
prsb03-dataelement-13156 (2020‑06‑24 16:06:14) 0.1
|
| Concept inherits from |
prsb03-dataelement-11995 (2019‑05‑31 15:12:02)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-13157
|
|
|
| Id |
prsb03-dataelement-13157 (2020‑06‑24 16:06:14) 0.1
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-13158
|
|
|
|
|
Organisation
prsb03-dataelement-13159
|
|
|
|
|
Professional identifier
prsb03-dataelement-13160
|
|
|
| Id |
prsb03-dataelement-13160 (2020‑06‑24 16:06:14) 0.1
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-13161
|
|
|
| Id |
prsb03-dataelement-13161 (2020‑06‑24 16:06:14) 0.1
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-13162
|
|
|
| Id |
prsb03-dataelement-13162 (2020‑06‑24 16:06:14) 0.1
|
| Concept inherits from |
prsb03-dataelement-12001 (2019‑05‑31 15:12:02)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
Medication discontinued entry
prsb03-dataelement-13163
|
|
|
|
|
Name of discontinued medication
prsb03-dataelement-13164
|
|
|
|
|
Status
prsb03-dataelement-13165
|
|
|
|
|
Status
prsb03-dataelement-13166
|
|
|
|
|
Indication
prsb03-dataelement-13167
|
|
|
|
|
Date of change
prsb03-dataelement-13168
|
|
|
| Id |
prsb03-dataelement-13168 (2020‑06‑24 16:06:14) 0.1
|
| Concept inherits from |
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 |
|
|
|
Description of amendment
prsb03-dataelement-13169
|
|
|
|
|
Comment
prsb03-dataelement-13170
|
|
|
|
|
Medical devices entry
prsb03-dataelement-13171
|
|
|
|
|
Medical device
prsb03-dataelement-13172
|
|
|
|
|
Comments
prsb03-dataelement-13173
|
|
|
|
|
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. |
|
|
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 |
|
|
|
prsb03-dataelement-12648
|
|
|
|
|
Medication item cluster
prsb03-dataelement-12649
|
|
|
|
|
Date
prsb03-dataelement-12650
|
|
|
| Id |
prsb03-dataelement-12650 (2019‑11‑19 17:11:10)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Date in dataset prsb03-dataelement-12707
|
|
|
Location
prsb03-dataelement-12651
|
|
|
| Id |
prsb03-dataelement-12651 (2019‑11‑19 17:11:10)
|
| Concept inherits from |
prsb03-dataelement-10844 (2019‑03‑27 17:01:20)
|
| Description |
The location where the medication or the medical device was prescribed. |
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Location in dataset prsb03-dataelement-12708
|
|
|
Performing professional
prsb03-dataelement-12652
|
|
|
| Id |
prsb03-dataelement-12652 (2019‑11‑19 17:11:10)
|
| Concept inherits from |
prsb03-dataelement-10845 (2019‑03‑27 17:01:47)
|
| Description |
Details of the professional prescribing the medication or medical device. |
| Value Domain |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Performing professional
prsb03-dataelement-12653
|
|
|
| Id |
prsb03-dataelement-12653 (2019‑11‑19 17:11:10)
|
| Concept inherits from |
prsb03-dataelement-12002 (2019‑05‑31 15:12:28)
|
| Description |
The professional who prescribed the medication or medical device. |
| Relationship |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Name
prsb03-dataelement-12654
|
|
|
| Id |
prsb03-dataelement-12654 (2019‑11‑19 17:11:10)
|
| Concept inherits from |
prsb03-dataelement-12003 (2019‑05‑31 15:12:48)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Name in dataset prsb03-dataelement-12711
|
|
|
Role
prsb03-dataelement-12655
|
|
|
| Id |
prsb03-dataelement-12655 (2019‑11‑19 17:11:10)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Role in dataset prsb03-dataelement-12712
|
|
|
Grade
prsb03-dataelement-12656
|
|
|
| Id |
prsb03-dataelement-12656 (2019‑11‑19 17:11:10)
|
| Concept inherits from |
prsb03-dataelement-12005 (2019‑05‑31 15:12:48)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Grade in dataset prsb03-dataelement-12713
|
|
|
Speciality
prsb03-dataelement-12657
|
|
|
| Id |
prsb03-dataelement-12657 (2019‑11‑19 17:11:10)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-12714
|
|
|
Professional identifier
prsb03-dataelement-12658
|
|
|
| Id |
prsb03-dataelement-12658 (2019‑11‑19 17:11:10)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Organisation
prsb03-dataelement-12659
|
|
|
| Id |
prsb03-dataelement-12659 (2019‑11‑19 17:11:10)
|
| Concept inherits from |
prsb03-dataelement-12008 (2019‑05‑31 15:12:48)
|
| Description |
The name of the organisation the professional works for. |
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-12716
|
|
|
Contact details
prsb03-dataelement-12660
|
|
|
| Id |
prsb03-dataelement-12660 (2019‑11‑19 17:11:10)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-12717
|
|
|
Medication name
prsb03-dataelement-12661
|
|
|
| Id |
prsb03-dataelement-12661 (2019‑11‑19 17:11:10)
|
| Concept inherits from |
prsb03-dataelement-10536 (2018‑10‑31)
|
| Description |
May be generic name or brand name. |
| 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)
|
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Medication name in dataset prsb03-dataelement-12718
|
|
|
Form
prsb03-dataelement-12662
|
|
|
| Id |
prsb03-dataelement-12662 (2019‑11‑19 17:11:10)
|
| Concept inherits from |
prsb03-dataelement-10537 (2018‑10‑31)
|
| Description |
The form of the medication e.g. capsule, drops, tablet, lotion etc. |
| 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
|
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Form in dataset prsb03-dataelement-12719
|
|
|
Quantity supplied
prsb03-dataelement-12663
|
|
|
| Id |
prsb03-dataelement-12663 (2019‑11‑19 17:11:10)
|
| Concept inherits from |
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
|
| FHIR |
MedicationStatement.quantityDispensed (Amount of medication to supply per dispense)
quantity (as a valueQuantity) - Mandatory quantityText (as a valueString) - Mandatory
|
|
| Operationalization |
Free text |
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Quantity supplied in dataset prsb03-dataelement-12720
|
|
|
Route
prsb03-dataelement-12664
|
|
|
| Id |
prsb03-dataelement-12664 (2019‑11‑19 17:11:10)
|
| Concept inherits from |
prsb03-dataelement-10538 (2018‑10‑31)
|
| Description |
The route by which the medication is administered e.g. oral, IM, IV |
| FHIR |
MedicationStatement.dosage.route |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Route in dataset prsb03-dataelement-12721
|
|
|
Site
prsb03-dataelement-12665
|
|
|
| Id |
prsb03-dataelement-12665 (2019‑11‑19 17:11:10)
|
| Concept inherits from |
prsb03-dataelement-10540 (2018‑10‑31)
|
| Description |
The anatomical site at which the medication is to be administered. |
| FHIR |
MedicationStatement.dosage.site |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Site in dataset prsb03-dataelement-12722
|
|
|
Method
prsb03-dataelement-12666
|
|
|
| Id |
prsb03-dataelement-12666 (2019‑11‑19 17:11:10)
|
| Concept inherits from |
prsb03-dataelement-10541 (2018‑10‑31)
|
| Description |
The technique or method by which the medication is to be administered. |
| FHIR |
MedicationStatement.dosage.method |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Method in dataset prsb03-dataelement-12723
|
|
|
Dose directions description
prsb03-dataelement-12667
|
|
|
| Id |
prsb03-dataelement-12667 (2019‑11‑19 17:11:10)
|
| Concept inherits from |
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”.
|
| FHIR |
MedicationStatement.dosage.text |
|
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Dose amount description
prsb03-dataelement-12668
|
|
|
| Id |
prsb03-dataelement-12668 (2019‑11‑19 17:11:10)
|
| Concept inherits from |
prsb03-dataelement-10542 (2018‑10‑31)
|
| Description |
A description of the medication single dose amount e.g. "30 mg" or "2 tabs". |
| FHIR |
MedicationStatement.dosage.text |
|
| Operationalization |
Free text |
| Value Domain |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Dose timing description
prsb03-dataelement-12669
|
|
|
| Id |
prsb03-dataelement-12669 (2019‑11‑19 17:11:10)
|
| Concept inherits from |
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".
|
| FHIR |
MedicationStatement.dosage.timing [a complex data type that holds lots of timing formats] |
|
| Operationalization |
Free text |
| Value Domain |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Parsable dose directions
prsb03-dataelement-12670
|
|
|
| Id |
prsb03-dataelement-12670 (2019‑11‑19 17:11:10)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Structured dose direction cluster
prsb03-dataelement-12671
|
|
|
| Id |
prsb03-dataelement-12671 (2019‑11‑19 17:11:10)
|
| Concept inherits from |
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.
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Structured dose direction
prsb03-dataelement-12672
|
|
|
|
|
Structured dose amount
prsb03-dataelement-12673
|
|
|
|
|
Structured dose timing
prsb03-dataelement-12674
|
|
|
| Id |
prsb03-dataelement-12674 (2019‑11‑19 17:11:10)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Dose direction duration
prsb03-dataelement-12675
|
|
|
| Id |
prsb03-dataelement-12675 (2019‑11‑19 17:11:10)
|
| Concept inherits from |
prsb03-dataelement-10548 (2018‑10‑31)
|
| Description |
Recommendation of the time period for which the medication should be continued, including
direction not to discontinue.
|
| 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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Prescribed quantity
prsb03-dataelement-12701
|
|
|
| Id |
prsb03-dataelement-12701 (2019‑11‑19 17:22:14)
|
| Description |
Medication quantity prescribed |
| Value Domain |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Authorised date
prsb03-dataelement-12702
|
|
|
| Id |
prsb03-dataelement-12702 (2019‑11‑19 17:23:30)
|
| Concept inherits from |
prsb03-dataelement-10558 (2018‑10‑31)
|
| Description |
Date prescriber created prescription |
| Operationalization |
Date and Time |
| Value Domain |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Authorised date in dataset prsb03-dataelement-12734
|
|
|
prsb03-dataelement-12703
|
|
|
| Id |
prsb03-dataelement-12703 (2019‑11‑19 17:24:54)
|
| Value Domain |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
in dataset prsb03-dataelement-12735
|
|
|
Valid from date
prsb03-dataelement-12704
|
|
|
| Id |
prsb03-dataelement-12704 (2019‑11‑19 17:24:55)
|
| Concept inherits from |
prsb03-dataelement-10560 (2018‑10‑31)
|
| Description |
Date the prescription can be issued from. Valid for 6 months |
| Operationalization |
Date and Time |
| Value Domain |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Valid from date in dataset prsb03-dataelement-12736
|
|
|
Indication
prsb03-dataelement-12705
|
|
|
| Id |
prsb03-dataelement-12705 (2019‑11‑19 17:26:09)
|
| Concept inherits from |
prsb03-dataelement-10579 (2018‑10‑31)
|
| Description |
The clinical indication for any changes in medication status |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Indication in dataset prsb03-dataelement-12737
|
|
|
Additional instructions
prsb03-dataelement-12676
|
|
|
| Id |
prsb03-dataelement-12676 (2019‑11‑19 17:11:10)
|
| Concept inherits from |
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.
|
| 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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Request for advice
prsb03-dataelement-12677
|
|
|
| Id |
prsb03-dataelement-12677 (2019‑11‑19 17:11:10)
|
| Concept inherits from |
prsb03-dataelement-10559 (2018‑10‑31)
|
| Description |
Request for advice and recommendation about medication |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Request for advice in dataset prsb03-dataelement-12739
|
|
|
Person completing record
prsb03-dataelement-12678
|
|
|
| Id |
prsb03-dataelement-12678 (2019‑11‑19 17:11:10)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Course details cluster
prsb03-dataelement-12679
|
|
|
|
|
Course status
prsb03-dataelement-12680
|
|
|
|
|
Indication
prsb03-dataelement-12681
|
|
|
| Id |
prsb03-dataelement-12681 (2019‑11‑19 17:11:10)
|
| Concept inherits from |
prsb03-dataelement-10546 (2018‑10‑31)
|
| Description |
Reason for medication being prescribed, where known. |
| FHIR |
MedicationStatement.reasonCode |
|
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Indication in dataset prsb03-dataelement-12743
|
|
|
Start date/time
prsb03-dataelement-12682
|
|
|
| Id |
prsb03-dataelement-12682 (2019‑11‑19 17:11:10)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Start date/time in dataset prsb03-dataelement-12744
|
|
|
End date/time
prsb03-dataelement-12683
|
|
|
| Id |
prsb03-dataelement-12683 (2019‑11‑19 17:11:10)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
End date/time in dataset prsb03-dataelement-12745
|
|
|
Link to indication record
prsb03-dataelement-12684
|
|
|
| Id |
prsb03-dataelement-12684 (2019‑11‑19 17:11:10)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Comment/recommendation
prsb03-dataelement-12685
|
|
|
| Id |
prsb03-dataelement-12685 (2019‑11‑19 17:11:10)
|
| Concept inherits from |
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
|
| FHIR |
[JH] This will be dropped from the PRSB information model, as conflicts with description
above
|
|
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Medication change summary cluster
prsb03-dataelement-12686
|
|
|
|
|
Status
prsb03-dataelement-12687
|
|
|
| Id |
prsb03-dataelement-12687 (2019‑11‑19 17:11:10)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Status in dataset prsb03-dataelement-12749
|
|
|
Indication
prsb03-dataelement-12688
|
|
|
| Id |
prsb03-dataelement-12688 (2019‑11‑19 17:11:10)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Indication in dataset prsb03-dataelement-12750
|
|
|
Date of change
prsb03-dataelement-12689
|
|
|
| Id |
prsb03-dataelement-12689 (2019‑11‑19 17:11:10)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Date of change in dataset prsb03-dataelement-12751
|
|
|
Description of amendment
prsb03-dataelement-12690
|
|
|
| Id |
prsb03-dataelement-12690 (2019‑11‑19 17:11:10)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Total dose daily quantity
prsb03-dataelement-12691
|
|
|
| Id |
prsb03-dataelement-12691 (2019‑11‑19 17:11:10)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Person completing record
prsb03-dataelement-12692
|
|
|
| Id |
prsb03-dataelement-12692 (2019‑11‑19 17:11:10)
|
| Concept inherits from |
prsb03-dataelement-11993 (2019‑05‑31 15:11:27)
|
| Description |
Details of the person completing the record. |
| Relationship |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Name
prsb03-dataelement-12693
|
|
|
| Id |
prsb03-dataelement-12693 (2019‑11‑19 17:11:10)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Name in dataset prsb03-dataelement-12755
|
|
|
Role
prsb03-dataelement-12694
|
|
|
| Id |
prsb03-dataelement-12694 (2019‑11‑19 17:11:10)
|
| Concept inherits from |
prsb03-dataelement-11995 (2019‑05‑31 15:12:02)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Role in dataset prsb03-dataelement-12756
|
|
|
Grade
prsb03-dataelement-12695
|
|
|
| Id |
prsb03-dataelement-12695 (2019‑11‑19 17:11:10)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Grade in dataset prsb03-dataelement-12757
|
|
|
Specialty
prsb03-dataelement-12696
|
|
|
| Id |
prsb03-dataelement-12696 (2019‑11‑19 17:11:10)
|
| Concept inherits from |
prsb03-dataelement-11997 (2019‑05‑31 15:12:02)
|
| Description |
The main specialty of the person completing the record. |
| FHIR |
PractitionerRole.specialty |
|
| Relationship |
|
| Rationale |
PractitionerRole.speciality |
| Operationalization |
NHS data dictionary :-
Activity treatment function code
|
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-12758
|
|
|
Organisation
prsb03-dataelement-12697
|
|
|
| Id |
prsb03-dataelement-12697 (2019‑11‑19 17:11:10)
|
| Concept inherits from |
prsb03-dataelement-11998 (2019‑05‑31 15:12:02)
|
| Description |
The organisation the person completing the record works for. |
| Relationship |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-12759
|
|
|
Professional identifier
prsb03-dataelement-12698
|
|
|
| Id |
prsb03-dataelement-12698 (2019‑11‑19 17:11:10)
|
| Concept inherits from |
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.
|
| 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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Date completed
prsb03-dataelement-12699
|
|
|
| Id |
prsb03-dataelement-12699 (2019‑11‑19 17:11:10)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-12761
|
|
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Contact details
prsb03-dataelement-12700
|
|
|
| Id |
prsb03-dataelement-12700 (2019‑11‑19 17:11:10)
|
| Concept inherits from |
prsb03-dataelement-12001 (2019‑05‑31 15:12:02)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-12762
|
|
|
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
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Repeat medications in dataset prsb03-dataelement-12602
|
|
|
Medication item cluster
prsb03-dataelement-12706
|
|
|
|
|
Date
prsb03-dataelement-12707
|
|
|
| Id |
prsb03-dataelement-12707 (2019‑11‑19 17:33:50)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Date in dataset prsb03-dataelement-12832
|
|
|
Location
prsb03-dataelement-12708
|
|
|
| Id |
prsb03-dataelement-12708 (2019‑11‑19 17:33:50)
|
| Concept inherits from |
prsb03-dataelement-12651 (2019‑11‑19 17:11:10)
|
| Description |
The location where the medication or the medical device was prescribed. |
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Location in dataset prsb03-dataelement-12833
|
|
|
Performing professional
prsb03-dataelement-12709
|
|
|
| Id |
prsb03-dataelement-12709 (2019‑11‑19 17:33:50)
|
| Concept inherits from |
prsb03-dataelement-12652 (2019‑11‑19 17:11:10)
|
| Description |
Details of the professional prescribing the medication or medical device. |
| Value Domain |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Performing professional
prsb03-dataelement-12710
|
|
|
| Id |
prsb03-dataelement-12710 (2019‑11‑19 17:33:50)
|
| Concept inherits from |
prsb03-dataelement-12653 (2019‑11‑19 17:11:10)
|
| Description |
The professional who prescribed the medication or medical device. |
| Relationship |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Name
prsb03-dataelement-12711
|
|
|
| Id |
prsb03-dataelement-12711 (2019‑11‑19 17:33:50)
|
| Concept inherits from |
prsb03-dataelement-12654 (2019‑11‑19 17:11:10)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Name in dataset prsb03-dataelement-12836
|
|
|
Role
prsb03-dataelement-12712
|
|
|
| Id |
prsb03-dataelement-12712 (2019‑11‑19 17:33:50)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Role in dataset prsb03-dataelement-12837
|
|
|
Grade
prsb03-dataelement-12713
|
|
|
| Id |
prsb03-dataelement-12713 (2019‑11‑19 17:33:50)
|
| Concept inherits from |
prsb03-dataelement-12656 (2019‑11‑19 17:11:10)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Grade in dataset prsb03-dataelement-12838
|
|
|
Speciality
prsb03-dataelement-12714
|
|
|
| Id |
prsb03-dataelement-12714 (2019‑11‑19 17:33:50)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-12839
|
|
|
Professional identifier
prsb03-dataelement-12715
|
|
|
| Id |
prsb03-dataelement-12715 (2019‑11‑19 17:33:50)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Organisation
prsb03-dataelement-12716
|
|
|
| Id |
prsb03-dataelement-12716 (2019‑11‑19 17:33:50)
|
| Concept inherits from |
prsb03-dataelement-12659 (2019‑11‑19 17:11:10)
|
| Description |
The name of the organisation the professional works for. |
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-12841
|
|
|
Contact details
prsb03-dataelement-12717
|
|
|
| Id |
prsb03-dataelement-12717 (2019‑11‑19 17:33:50)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-12842
|
|
|
Medication name
prsb03-dataelement-12718
|
|
|
| Id |
prsb03-dataelement-12718 (2019‑11‑19 17:33:50)
|
| Concept inherits from |
prsb03-dataelement-12661 (2019‑11‑19 17:11:10)
|
| Description |
May be generic name or brand name. |
| 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)
|
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Medication name in dataset prsb03-dataelement-12843
|
|
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Form
prsb03-dataelement-12719
|
|
|
| Id |
prsb03-dataelement-12719 (2019‑11‑19 17:33:50)
|
| Concept inherits from |
prsb03-dataelement-12662 (2019‑11‑19 17:11:10)
|
| Description |
The form of the medication e.g. capsule, drops, tablet, lotion etc. |
| 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
|
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Form in dataset prsb03-dataelement-12844
|
|
|
Quantity supplied
prsb03-dataelement-12720
|
|
|
| Id |
prsb03-dataelement-12720 (2019‑11‑19 17:33:50)
|
| Concept inherits from |
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
|
| FHIR |
MedicationStatement.quantityDispensed (Amount of medication to supply per dispense)
quantity (as a valueQuantity) - Mandatory quantityText (as a valueString) - Mandatory
|
|
| Operationalization |
Free text |
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Quantity supplied in dataset prsb03-dataelement-12845
|
|
|
Route
prsb03-dataelement-12721
|
|
|
| Id |
prsb03-dataelement-12721 (2019‑11‑19 17:33:50)
|
| Concept inherits from |
prsb03-dataelement-12664 (2019‑11‑19 17:11:10)
|
| Description |
The route by which the medication is administered e.g. oral, IM, IV |
| FHIR |
MedicationStatement.dosage.route |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Route in dataset prsb03-dataelement-12846
|
|
|
Site
prsb03-dataelement-12722
|
|
|
| Id |
prsb03-dataelement-12722 (2019‑11‑19 17:33:50)
|
| Concept inherits from |
prsb03-dataelement-12665 (2019‑11‑19 17:11:10)
|
| Description |
The anatomical site at which the medication is to be administered. |
| FHIR |
MedicationStatement.dosage.site |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Site in dataset prsb03-dataelement-12847
|
|
|
Method
prsb03-dataelement-12723
|
|
|
| Id |
prsb03-dataelement-12723 (2019‑11‑19 17:33:50)
|
| Concept inherits from |
prsb03-dataelement-12666 (2019‑11‑19 17:11:10)
|
| Description |
The technique or method by which the medication is to be administered. |
| FHIR |
MedicationStatement.dosage.method |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Method in dataset prsb03-dataelement-12848
|
|
|
Dose directions description
prsb03-dataelement-12724
|
|
|
| Id |
prsb03-dataelement-12724 (2019‑11‑19 17:33:50)
|
| Concept inherits from |
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”.
|
| FHIR |
MedicationStatement.dosage.text |
|
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Dose amount description
prsb03-dataelement-12725
|
|
|
| Id |
prsb03-dataelement-12725 (2019‑11‑19 17:33:50)
|
| Concept inherits from |
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". |
| FHIR |
MedicationStatement.dosage.text |
|
| Operationalization |
Free text |
| Value Domain |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Dose timing description
prsb03-dataelement-12726
|
|
|
| Id |
prsb03-dataelement-12726 (2019‑11‑19 17:33:50)
|
| Concept inherits from |
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".
|
| FHIR |
MedicationStatement.dosage.timing [a complex data type that holds lots of timing formats] |
|
| Operationalization |
Free text |
| Value Domain |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Parsable dose directions
prsb03-dataelement-12727
|
|
|
| Id |
prsb03-dataelement-12727 (2019‑11‑19 17:33:50)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Structured dose direction cluster
prsb03-dataelement-12728
|
|
|
| Id |
prsb03-dataelement-12728 (2019‑11‑19 17:33:50)
|
| Concept inherits from |
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.
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Structured dose direction
prsb03-dataelement-12729
|
|
|
|
|
Structured dose amount
prsb03-dataelement-12730
|
|
|
| Id |
prsb03-dataelement-12730 (2019‑11‑19 17:33:50)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Structured dose timing
prsb03-dataelement-12731
|
|
|
| Id |
prsb03-dataelement-12731 (2019‑11‑19 17:33:50)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Dose direction duration
prsb03-dataelement-12732
|
|
|
| Id |
prsb03-dataelement-12732 (2019‑11‑19 17:33:50)
|
| Concept inherits from |
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.
|
| 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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Prescribed quantity
prsb03-dataelement-12733
|
|
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Date started in dataset prsb03-dataelement-12859
|
|
|
Authorised date
prsb03-dataelement-12734
|
|
|
| Id |
prsb03-dataelement-12734 (2019‑11‑19 17:33:50)
|
| Concept inherits from |
prsb03-dataelement-12702 (2019‑11‑19 17:23:30)
|
| Description |
Date prescriber created prescription |
| Operationalization |
Date and Time |
| Value Domain |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Authorised date in dataset prsb03-dataelement-12860
|
|
|
prsb03-dataelement-12735
|
|
|
| Id |
prsb03-dataelement-12735 (2019‑11‑19 17:33:50)
|
| Concept inherits from |
prsb03-dataelement-12703 (2019‑11‑19 17:24:54)
|
| Value Domain |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
in dataset prsb03-dataelement-12861
|
|
|
Valid from date
prsb03-dataelement-12736
|
|
|
| Id |
prsb03-dataelement-12736 (2019‑11‑19 17:33:50)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Valid from date in dataset prsb03-dataelement-12862
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Valid to date in dataset prsb03-dataelement-12865
|
|
|
Indication
prsb03-dataelement-12737
|
|
|
| Id |
prsb03-dataelement-12737 (2019‑11‑19 17:33:50)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Indication in dataset prsb03-dataelement-12866
|
|
|
Additional instructions
prsb03-dataelement-12738
|
|
|
| Id |
prsb03-dataelement-12738 (2019‑11‑19 17:33:50)
|
| Concept inherits from |
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.
|
| 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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Request for advice
prsb03-dataelement-12739
|
|
|
| Id |
prsb03-dataelement-12739 (2019‑11‑19 17:33:50)
|
| Concept inherits from |
prsb03-dataelement-12677 (2019‑11‑19 17:11:10)
|
| Description |
Request for advice and recommendation about medication |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Request for advice in dataset prsb03-dataelement-12868
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Request dispensed in dataset prsb03-dataelement-12869
|
|
|
Person completing record
prsb03-dataelement-12740
|
|
|
| Id |
prsb03-dataelement-12740 (2019‑11‑19 17:33:50)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Course details cluster
prsb03-dataelement-12741
|
|
|
|
|
Course status
prsb03-dataelement-12742
|
|
|
|
|
Indication
prsb03-dataelement-12743
|
|
|
| Id |
prsb03-dataelement-12743 (2019‑11‑19 17:33:50)
|
| Concept inherits from |
prsb03-dataelement-12681 (2019‑11‑19 17:11:10)
|
| Description |
Reason for medication being prescribed, where known. |
| FHIR |
MedicationStatement.reasonCode |
|
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Indication in dataset prsb03-dataelement-12873
|
|
|
Start date/time
prsb03-dataelement-12744
|
|
|
| Id |
prsb03-dataelement-12744 (2019‑11‑19 17:33:50)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Start date/time in dataset prsb03-dataelement-12874
|
|
|
End date/time
prsb03-dataelement-12745
|
|
|
| Id |
prsb03-dataelement-12745 (2019‑11‑19 17:33:50)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
End date/time in dataset prsb03-dataelement-12875
|
|
|
Link to indication record
prsb03-dataelement-12746
|
|
|
| Id |
prsb03-dataelement-12746 (2019‑11‑19 17:33:50)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Comment/recommendation
prsb03-dataelement-12747
|
|
|
| Id |
prsb03-dataelement-12747 (2019‑11‑19 17:33:50)
|
| Concept inherits from |
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
|
| FHIR |
[JH] This will be dropped from the PRSB information model, as conflicts with description
above
|
|
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Medication change summary cluster
prsb03-dataelement-12748
|
|
|
|
|
Status
prsb03-dataelement-12749
|
|
|
| Id |
prsb03-dataelement-12749 (2019‑11‑19 17:33:50)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Status in dataset prsb03-dataelement-12879
|
|
|
Indication
prsb03-dataelement-12750
|
|
|
| Id |
prsb03-dataelement-12750 (2019‑11‑19 17:33:50)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Indication in dataset prsb03-dataelement-12880
|
|
|
Date of change
prsb03-dataelement-12751
|
|
|
| Id |
prsb03-dataelement-12751 (2019‑11‑19 17:33:50)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Date of change in dataset prsb03-dataelement-12881
|
|
|
Description of amendment
prsb03-dataelement-12752
|
|
|
| Id |
prsb03-dataelement-12752 (2019‑11‑19 17:33:50)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Total dose daily quantity
prsb03-dataelement-12753
|
|
|
| Id |
prsb03-dataelement-12753 (2019‑11‑19 17:33:50)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Person completing record
prsb03-dataelement-12754
|
|
|
| Id |
prsb03-dataelement-12754 (2019‑11‑19 17:33:50)
|
| Concept inherits from |
prsb03-dataelement-12692 (2019‑11‑19 17:11:10)
|
| Description |
Details of the person completing the record. |
| Relationship |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Name
prsb03-dataelement-12755
|
|
|
| Id |
prsb03-dataelement-12755 (2019‑11‑19 17:33:50)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Name in dataset prsb03-dataelement-12885
|
|
|
Role
prsb03-dataelement-12756
|
|
|
| Id |
prsb03-dataelement-12756 (2019‑11‑19 17:33:50)
|
| Concept inherits from |
prsb03-dataelement-12694 (2019‑11‑19 17:11:10)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Role in dataset prsb03-dataelement-12886
|
|
|
Grade
prsb03-dataelement-12757
|
|
|
| Id |
prsb03-dataelement-12757 (2019‑11‑19 17:33:50)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Grade in dataset prsb03-dataelement-12887
|
|
|
Specialty
prsb03-dataelement-12758
|
|
|
| Id |
prsb03-dataelement-12758 (2019‑11‑19 17:33:50)
|
| Concept inherits from |
prsb03-dataelement-12696 (2019‑11‑19 17:11:10)
|
| Description |
The main specialty of the person completing the record. |
| FHIR |
PractitionerRole.specialty |
|
| Relationship |
|
| Rationale |
PractitionerRole.speciality |
| Operationalization |
NHS data dictionary :-
Activity treatment function code
|
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-12888
|
|
|
Organisation
prsb03-dataelement-12759
|
|
|
| Id |
prsb03-dataelement-12759 (2019‑11‑19 17:33:50)
|
| Concept inherits from |
prsb03-dataelement-12697 (2019‑11‑19 17:11:10)
|
| Description |
The organisation the person completing the record works for. |
| Relationship |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-12889
|
|
|
Professional identifier
prsb03-dataelement-12760
|
|
|
| Id |
prsb03-dataelement-12760 (2019‑11‑19 17:33:50)
|
| Concept inherits from |
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.
|
| 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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Date completed
prsb03-dataelement-12761
|
|
|
| Id |
prsb03-dataelement-12761 (2019‑11‑19 17:33:50)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-12891
|
|
|
Contact details
prsb03-dataelement-12762
|
|
|
| Id |
prsb03-dataelement-12762 (2019‑11‑19 17:33:50)
|
| Concept inherits from |
prsb03-dataelement-12700 (2019‑11‑19 17:11:10)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-12892
|
|
|
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. |
|
|
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 |
|
|
|
Medication item cluster
prsb03-dataelement-12770
|
|
|
|
|
Date
prsb03-dataelement-12832
|
|
|
| Id |
prsb03-dataelement-12832 (2019‑11‑19 17:57:19)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Date in dataset prsb03-dataelement-12897
|
|
|
Location
prsb03-dataelement-12833
|
|
|
| Id |
prsb03-dataelement-12833 (2019‑11‑19 17:57:19)
|
| Concept inherits from |
prsb03-dataelement-12708 (2019‑11‑19 17:33:50)
|
| Description |
The location where the medication or the medical device was prescribed. |
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Location in dataset prsb03-dataelement-12898
|
|
|
Performing professional
prsb03-dataelement-12834
|
|
|
| Id |
prsb03-dataelement-12834 (2019‑11‑19 17:57:19)
|
| Concept inherits from |
prsb03-dataelement-12709 (2019‑11‑19 17:33:50)
|
| Description |
Details of the professional prescribing the medication or medical device. |
| Value Domain |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Performing professional
prsb03-dataelement-12835
|
|
|
| Id |
prsb03-dataelement-12835 (2019‑11‑19 17:57:19)
|
| Concept inherits from |
prsb03-dataelement-12710 (2019‑11‑19 17:33:50)
|
| Description |
The professional who prescribed the medication or medical device. |
| Relationship |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Name
prsb03-dataelement-12836
|
|
|
| Id |
prsb03-dataelement-12836 (2019‑11‑19 17:57:19)
|
| Concept inherits from |
prsb03-dataelement-12711 (2019‑11‑19 17:33:50)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Name in dataset prsb03-dataelement-12901
|
|
|
Role
prsb03-dataelement-12837
|
|
|
| Id |
prsb03-dataelement-12837 (2019‑11‑19 17:57:19)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Role in dataset prsb03-dataelement-12902
|
|
|
Grade
prsb03-dataelement-12838
|
|
|
| Id |
prsb03-dataelement-12838 (2019‑11‑19 17:57:19)
|
| Concept inherits from |
prsb03-dataelement-12713 (2019‑11‑19 17:33:50)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Grade in dataset prsb03-dataelement-12903
|
|
|
Speciality
prsb03-dataelement-12839
|
|
|
| Id |
prsb03-dataelement-12839 (2019‑11‑19 17:57:19)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-12904
|
|
|
Professional identifier
prsb03-dataelement-12840
|
|
|
| Id |
prsb03-dataelement-12840 (2019‑11‑19 17:57:19)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Organisation
prsb03-dataelement-12841
|
|
|
| Id |
prsb03-dataelement-12841 (2019‑11‑19 17:57:19)
|
| Concept inherits from |
prsb03-dataelement-12716 (2019‑11‑19 17:33:50)
|
| Description |
The name of the organisation the professional works for. |
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-12906
|
|
|
Contact details
prsb03-dataelement-12842
|
|
|
| Id |
prsb03-dataelement-12842 (2019‑11‑19 17:57:19)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-12907
|
|
|
Medication name
prsb03-dataelement-12843
|
|
|
| Id |
prsb03-dataelement-12843 (2019‑11‑19 17:57:19)
|
| Concept inherits from |
prsb03-dataelement-12718 (2019‑11‑19 17:33:50)
|
| Description |
May be generic name or brand name. |
| 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)
|
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Medication name in dataset prsb03-dataelement-12908
|
|
|
Form
prsb03-dataelement-12844
|
|
|
| Id |
prsb03-dataelement-12844 (2019‑11‑19 17:57:19)
|
| Concept inherits from |
prsb03-dataelement-12719 (2019‑11‑19 17:33:50)
|
| Description |
The form of the medication e.g. capsule, drops, tablet, lotion etc. |
| 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
|
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Form in dataset prsb03-dataelement-12909
|
|
|
Quantity supplied
prsb03-dataelement-12845
|
|
|
| Id |
prsb03-dataelement-12845 (2019‑11‑19 17:57:19)
|
| Concept inherits from |
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
|
| FHIR |
MedicationStatement.quantityDispensed (Amount of medication to supply per dispense)
quantity (as a valueQuantity) - Mandatory quantityText (as a valueString) - Mandatory
|
|
| Operationalization |
Free text |
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Quantity supplied in dataset prsb03-dataelement-12910
|
|
|
Route
prsb03-dataelement-12846
|
|
|
| Id |
prsb03-dataelement-12846 (2019‑11‑19 17:57:19)
|
| Concept inherits from |
prsb03-dataelement-12721 (2019‑11‑19 17:33:50)
|
| Description |
The route by which the medication is administered e.g. oral, IM, IV |
| FHIR |
MedicationStatement.dosage.route |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Route in dataset prsb03-dataelement-12911
|
|
|
Site
prsb03-dataelement-12847
|
|
|
| Id |
prsb03-dataelement-12847 (2019‑11‑19 17:57:19)
|
| Concept inherits from |
prsb03-dataelement-12722 (2019‑11‑19 17:33:50)
|
| Description |
The anatomical site at which the medication is to be administered. |
| FHIR |
MedicationStatement.dosage.site |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Site in dataset prsb03-dataelement-12912
|
|
|
Method
prsb03-dataelement-12848
|
|
|
| Id |
prsb03-dataelement-12848 (2019‑11‑19 17:57:19)
|
| Concept inherits from |
prsb03-dataelement-12723 (2019‑11‑19 17:33:50)
|
| Description |
The technique or method by which the medication is to be administered. |
| FHIR |
MedicationStatement.dosage.method |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Method in dataset prsb03-dataelement-12913
|
|
|
Dose directions description
prsb03-dataelement-12849
|
|
|
| Id |
prsb03-dataelement-12849 (2019‑11‑19 17:57:19)
|
| Concept inherits from |
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”.
|
| FHIR |
MedicationStatement.dosage.text |
|
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Dose amount description
prsb03-dataelement-12850
|
|
|
| Id |
prsb03-dataelement-12850 (2019‑11‑19 17:57:19)
|
| Concept inherits from |
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". |
| FHIR |
MedicationStatement.dosage.text |
|
| Operationalization |
Free text |
| Value Domain |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Dose timing description
prsb03-dataelement-12851
|
|
|
| Id |
prsb03-dataelement-12851 (2019‑11‑19 17:57:19)
|
| Concept inherits from |
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".
|
| FHIR |
MedicationStatement.dosage.timing [a complex data type that holds lots of timing formats] |
|
| Operationalization |
Free text |
| Value Domain |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Parsable dose directions
prsb03-dataelement-12852
|
|
|
| Id |
prsb03-dataelement-12852 (2019‑11‑19 17:57:19)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Structured dose direction cluster
prsb03-dataelement-12853
|
|
|
| Id |
prsb03-dataelement-12853 (2019‑11‑19 17:57:19)
|
| Concept inherits from |
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.
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Structured dose direction
prsb03-dataelement-12854
|
|
|
|
|
Structured dose amount
prsb03-dataelement-12855
|
|
|
| Id |
prsb03-dataelement-12855 (2019‑11‑19 17:57:19)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Structured dose timing
prsb03-dataelement-12856
|
|
|
| Id |
prsb03-dataelement-12856 (2019‑11‑19 17:57:19)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Dose direction duration
prsb03-dataelement-12857
|
|
|
| Id |
prsb03-dataelement-12857 (2019‑11‑19 17:57:19)
|
| Concept inherits from |
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.
|
| 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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Prescribed quantity
prsb03-dataelement-12858
|
|
|
|
|
Date started
prsb03-dataelement-12859
|
|
|
| Id |
prsb03-dataelement-12859 (2019‑11‑19 17:57:19)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Date started in dataset prsb03-dataelement-12924
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Date discontinued in dataset prsb03-dataelement-12925
|
|
|
Authorised date
prsb03-dataelement-12860
|
|
|
| Id |
prsb03-dataelement-12860 (2019‑11‑19 17:57:19)
|
| Concept inherits from |
prsb03-dataelement-12734 (2019‑11‑19 17:33:50)
|
| Description |
Date prescriber created prescription |
| Operationalization |
Date and Time |
| Value Domain |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Authorised date in dataset prsb03-dataelement-12926
|
|
|
prsb03-dataelement-12861
|
|
|
| Id |
prsb03-dataelement-12861 (2019‑11‑19 17:57:19)
|
| Concept inherits from |
prsb03-dataelement-12735 (2019‑11‑19 17:33:50)
|
| Value Domain |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
in dataset prsb03-dataelement-12927
|
|
|
Valid from date
prsb03-dataelement-12862
|
|
|
| Id |
prsb03-dataelement-12862 (2019‑11‑19 17:57:19)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Valid from date in dataset prsb03-dataelement-12928
|
|
|
Number of issues permissable
prsb03-dataelement-12863
|
|
|
|
|
Number of issues made
prsb03-dataelement-12864
|
|
|
|
|
Valid to date
prsb03-dataelement-12865
|
|
|
| Id |
prsb03-dataelement-12865 (2019‑11‑19 17:57:19)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Valid to date in dataset prsb03-dataelement-12931
|
|
|
Indication
prsb03-dataelement-12866
|
|
|
| Id |
prsb03-dataelement-12866 (2019‑11‑19 17:57:19)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Indication in dataset prsb03-dataelement-12932
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Additional instructions
prsb03-dataelement-12867
|
|
|
| Id |
prsb03-dataelement-12867 (2019‑11‑19 17:57:19)
|
| Concept inherits from |
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.
|
| 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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Request for advice
prsb03-dataelement-12868
|
|
|
| Id |
prsb03-dataelement-12868 (2019‑11‑19 17:57:19)
|
| Concept inherits from |
prsb03-dataelement-12739 (2019‑11‑19 17:33:50)
|
| Description |
Request for advice and recommendation about medication |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Request for advice in dataset prsb03-dataelement-12935
|
|
|
Request dispensed
prsb03-dataelement-12869
|
|
|
| Id |
prsb03-dataelement-12869 (2019‑11‑19 17:57:19)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Request dispensed in dataset prsb03-dataelement-12936
|
|
|
Person completing record
prsb03-dataelement-12870
|
|
|
| Id |
prsb03-dataelement-12870 (2019‑11‑19 17:57:19)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Course details cluster
prsb03-dataelement-12871
|
|
|
|
|
Course status
prsb03-dataelement-12872
|
|
|
|
|
Indication
prsb03-dataelement-12873
|
|
|
| Id |
prsb03-dataelement-12873 (2019‑11‑19 17:57:19)
|
| Concept inherits from |
prsb03-dataelement-12743 (2019‑11‑19 17:33:50)
|
| Description |
Reason for medication being prescribed, where known. |
| FHIR |
MedicationStatement.reasonCode |
|
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Indication in dataset prsb03-dataelement-12940
|
|
|
Start date/time
prsb03-dataelement-12874
|
|
|
| Id |
prsb03-dataelement-12874 (2019‑11‑19 17:57:19)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Start date/time in dataset prsb03-dataelement-12941
|
|
|
End date/time
prsb03-dataelement-12875
|
|
|
| Id |
prsb03-dataelement-12875 (2019‑11‑19 17:57:19)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
End date/time in dataset prsb03-dataelement-12942
|
|
|
Link to indication record
prsb03-dataelement-12876
|
|
|
| Id |
prsb03-dataelement-12876 (2019‑11‑19 17:57:19)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Comment/recommendation
prsb03-dataelement-12877
|
|
|
| Id |
prsb03-dataelement-12877 (2019‑11‑19 17:57:19)
|
| Concept inherits from |
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
|
| FHIR |
[JH] This will be dropped from the PRSB information model, as conflicts with description
above
|
|
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Medication change summary cluster
prsb03-dataelement-12878
|
|
|
|
|
Status
prsb03-dataelement-12879
|
|
|
| Id |
prsb03-dataelement-12879 (2019‑11‑19 17:57:19)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Status in dataset prsb03-dataelement-12946
|
|
|
Indication
prsb03-dataelement-12880
|
|
|
| Id |
prsb03-dataelement-12880 (2019‑11‑19 17:57:19)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Indication in dataset prsb03-dataelement-12947
|
|
|
Date of change
prsb03-dataelement-12881
|
|
|
| Id |
prsb03-dataelement-12881 (2019‑11‑19 17:57:19)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Date of change in dataset prsb03-dataelement-12948
|
|
|
Description of amendment
prsb03-dataelement-12882
|
|
|
| Id |
prsb03-dataelement-12882 (2019‑11‑19 17:57:19)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Total dose daily quantity
prsb03-dataelement-12883
|
|
|
| Id |
prsb03-dataelement-12883 (2019‑11‑19 17:57:19)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Person completing record
prsb03-dataelement-12884
|
|
|
| Id |
prsb03-dataelement-12884 (2019‑11‑19 17:57:19)
|
| Concept inherits from |
prsb03-dataelement-12754 (2019‑11‑19 17:33:50)
|
| Description |
Details of the person completing the record. |
| Relationship |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Name
prsb03-dataelement-12885
|
|
|
| Id |
prsb03-dataelement-12885 (2019‑11‑19 17:57:19)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Name in dataset prsb03-dataelement-12952
|
|
|
Role
prsb03-dataelement-12886
|
|
|
| Id |
prsb03-dataelement-12886 (2019‑11‑19 17:57:19)
|
| Concept inherits from |
prsb03-dataelement-12756 (2019‑11‑19 17:33:50)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Role in dataset prsb03-dataelement-12953
|
|
|
Grade
prsb03-dataelement-12887
|
|
|
| Id |
prsb03-dataelement-12887 (2019‑11‑19 17:57:19)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Grade in dataset prsb03-dataelement-12954
|
|
|
Specialty
prsb03-dataelement-12888
|
|
|
| Id |
prsb03-dataelement-12888 (2019‑11‑19 17:57:19)
|
| Concept inherits from |
prsb03-dataelement-12758 (2019‑11‑19 17:33:50)
|
| Description |
The main specialty of the person completing the record. |
| FHIR |
PractitionerRole.specialty |
|
| Relationship |
|
| Rationale |
PractitionerRole.speciality |
| Operationalization |
NHS data dictionary :-
Activity treatment function code
|
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-12955
|
|
|
Organisation
prsb03-dataelement-12889
|
|
|
| Id |
prsb03-dataelement-12889 (2019‑11‑19 17:57:19)
|
| Concept inherits from |
prsb03-dataelement-12759 (2019‑11‑19 17:33:50)
|
| Description |
The organisation the person completing the record works for. |
| Relationship |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-12956
|
|
|
Professional identifier
prsb03-dataelement-12890
|
|
|
| Id |
prsb03-dataelement-12890 (2019‑11‑19 17:57:19)
|
| Concept inherits from |
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.
|
| 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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Date completed
prsb03-dataelement-12891
|
|
|
| Id |
prsb03-dataelement-12891 (2019‑11‑19 17:57:19)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-12958
|
|
|
Contact details
prsb03-dataelement-12892
|
|
|
| Id |
prsb03-dataelement-12892 (2019‑11‑19 17:57:19)
|
| Concept inherits from |
prsb03-dataelement-12762 (2019‑11‑19 17:33:50)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-12959
|
|
|
Prescribed elsewhere
prsb03-dataelement-12895
|
|
|
| Id |
prsb03-dataelement-12895 (2019‑11‑20 12:01:16)
|
| Description |
Prescribed elsewhere: Medication managed by another organisation |
| Relationship |
|
|
|
Medication item cluster
prsb03-dataelement-12896
|
|
|
|
|
Date
prsb03-dataelement-12897
|
|
|
| Id |
prsb03-dataelement-12897 (2019‑11‑20 12:13:29)
|
| Concept inherits from |
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 |
|
|
|
Location
prsb03-dataelement-12898
|
|
|
|
|
Performing professional
prsb03-dataelement-12899
|
|
|
|
|
Performing professional
prsb03-dataelement-12900
|
|
|
|
|
Name
prsb03-dataelement-12901
|
|
|
| Id |
prsb03-dataelement-12901 (2019‑11‑20 12:13:29)
|
| Concept inherits from |
prsb03-dataelement-12836 (2019‑11‑19 17:57:19)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
|
|
Role
prsb03-dataelement-12902
|
|
|
| Id |
prsb03-dataelement-12902 (2019‑11‑20 12:13:29)
|
| Concept inherits from |
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 |
|
|
|
Grade
prsb03-dataelement-12903
|
|
|
| Id |
prsb03-dataelement-12903 (2019‑11‑20 12:13:29)
|
| Concept inherits from |
prsb03-dataelement-12838 (2019‑11‑19 17:57:19)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Speciality
prsb03-dataelement-12904
|
|
|
|
|
Professional identifier
prsb03-dataelement-12905
|
|
|
| Id |
prsb03-dataelement-12905 (2019‑11‑20 12:13:29)
|
| Concept inherits from |
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 |
|
|
|
Organisation
prsb03-dataelement-12906
|
|
|
|
|
Contact details
prsb03-dataelement-12907
|
|
|
| Id |
prsb03-dataelement-12907 (2019‑11‑20 12:13:29)
|
| Concept inherits from |
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 |
|
|
|
Medication name
prsb03-dataelement-12908
|
|
|
| Id |
prsb03-dataelement-12908 (2019‑11‑20 12:13:29)
|
| Concept inherits from |
prsb03-dataelement-12843 (2019‑11‑19 17:57:19)
|
| Description |
May be generic name or brand name. |
| 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)
|
|
|
|
Form
prsb03-dataelement-12909
|
|
|
| Id |
prsb03-dataelement-12909 (2019‑11‑20 12:13:29)
|
| Concept inherits from |
prsb03-dataelement-12844 (2019‑11‑19 17:57:19)
|
| Description |
The form of the medication e.g. capsule, drops, tablet, lotion etc. |
| 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
|
|
|
|
Quantity supplied
prsb03-dataelement-12910
|
|
|
| Id |
prsb03-dataelement-12910 (2019‑11‑20 12:13:29)
|
| Concept inherits from |
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
|
| FHIR |
MedicationStatement.quantityDispensed (Amount of medication to supply per dispense)
quantity (as a valueQuantity) - Mandatory quantityText (as a valueString) - Mandatory
|
|
| Operationalization |
Free text |
|
|
Route
prsb03-dataelement-12911
|
|
|
|
|
Site
prsb03-dataelement-12912
|
|
|
|
|
Method
prsb03-dataelement-12913
|
|
|
| Id |
prsb03-dataelement-12913 (2019‑11‑20 12:13:29)
|
| Concept inherits from |
prsb03-dataelement-12848 (2019‑11‑19 17:57:19)
|
| Description |
The technique or method by which the medication is to be administered. |
| FHIR |
MedicationStatement.dosage.method |
|
|
|
Dose directions description
prsb03-dataelement-12914
|
|
|
| Id |
prsb03-dataelement-12914 (2019‑11‑20 12:13:29)
|
| Concept inherits from |
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”.
|
| FHIR |
MedicationStatement.dosage.text |
|
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Dose amount description
prsb03-dataelement-12915
|
|
|
| Id |
prsb03-dataelement-12915 (2019‑11‑20 12:13:29)
|
| Concept inherits from |
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". |
| FHIR |
MedicationStatement.dosage.text |
|
| Operationalization |
Free text |
| Value Domain |
|
|
|
Dose timing description
prsb03-dataelement-12916
|
|
|
| Id |
prsb03-dataelement-12916 (2019‑11‑20 12:13:29)
|
| Concept inherits from |
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".
|
| FHIR |
MedicationStatement.dosage.timing [a complex data type that holds lots of timing formats] |
|
| Operationalization |
Free text |
| Value Domain |
|
|
|
Parsable dose directions
prsb03-dataelement-12917
|
|
|
| Id |
prsb03-dataelement-12917 (2019‑11‑20 12:13:29)
|
| Concept inherits from |
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 |
|
|
|
Structured dose direction cluster
prsb03-dataelement-12918
|
|
|
| Id |
prsb03-dataelement-12918 (2019‑11‑20 12:13:29)
|
| Concept inherits from |
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.
|
|
|
Structured dose direction
prsb03-dataelement-12919
|
|
|
|
|
Structured dose amount
prsb03-dataelement-12920
|
|
|
|
|
Structured dose timing
prsb03-dataelement-12921
|
|
|
|
|
Dose direction duration
prsb03-dataelement-12922
|
|
|
| Id |
prsb03-dataelement-12922 (2019‑11‑20 12:13:29)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Prescribed quantity
prsb03-dataelement-12923
|
|
|
|
|
Date started
prsb03-dataelement-12924
|
|
|
| Id |
prsb03-dataelement-12924 (2019‑11‑20 12:13:29)
|
| Concept inherits from |
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 |
|
|
|
Date discontinued
prsb03-dataelement-12925
|
|
|
| Id |
prsb03-dataelement-12925 (2019‑11‑20 12:13:29)
|
| Concept inherits from |
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 |
|
|
|
Authorised date
prsb03-dataelement-12926
|
|
|
|
|
prsb03-dataelement-12927
|
|
|
|
|
Valid from date
prsb03-dataelement-12928
|
|
|
|
|
Number of issues permissable
prsb03-dataelement-12929
|
|
|
|
|
Number of issues made
prsb03-dataelement-12930
|
|
|
|
|
Valid to date
prsb03-dataelement-12931
|
|
|
|
|
Indication
prsb03-dataelement-12932
|
|
|
| Id |
prsb03-dataelement-12932 (2019‑11‑20 12:13:29)
|
| Concept inherits from |
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 |
|
|
|
Reason for discontinuation
prsb03-dataelement-12933
|
|
|
|
|
Additional instructions
prsb03-dataelement-12934
|
|
|
| Id |
prsb03-dataelement-12934 (2019‑11‑20 12:13:29)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
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 |
|
|
|
Organisation
prsb03-dataelement-12961
|
|
|
| Id |
prsb03-dataelement-12961 (2019‑11‑20 12:25:46)
|
| Description |
Prescribing organisation |
| Operationalization |
ODS code |
| Value Domain |
|
|
|
Request for advice
prsb03-dataelement-12935
|
|
|
|
|
Request dispensed
prsb03-dataelement-12936
|
|
|
| Id |
prsb03-dataelement-12936 (2019‑11‑20 12:13:29)
|
| Concept inherits from |
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 |
|
|
|
Person completing record
prsb03-dataelement-12937
|
|
|
| Id |
prsb03-dataelement-12937 (2019‑11‑20 12:13:29)
|
| Concept inherits from |
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 |
|
|
|
Course details cluster
prsb03-dataelement-12938
|
|
|
|
|
Course status
prsb03-dataelement-12939
|
|
|
|
|
Indication
prsb03-dataelement-12940
|
|
|
| Id |
prsb03-dataelement-12940 (2019‑11‑20 12:13:29)
|
| Concept inherits from |
prsb03-dataelement-12873 (2019‑11‑19 17:57:19)
|
| Description |
Reason for medication being prescribed, where known. |
| FHIR |
MedicationStatement.reasonCode |
|
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Start date/time
prsb03-dataelement-12941
|
|
|
| Id |
prsb03-dataelement-12941 (2019‑11‑20 12:13:29)
|
| Concept inherits from |
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 |
|
|
|
End date/time
prsb03-dataelement-12942
|
|
|
| Id |
prsb03-dataelement-12942 (2019‑11‑20 12:13:29)
|
| Concept inherits from |
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 |
|
|
|
Link to indication record
prsb03-dataelement-12943
|
|
|
| Id |
prsb03-dataelement-12943 (2019‑11‑20 12:13:29)
|
| Concept inherits from |
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 |
|
|
|
Comment/recommendation
prsb03-dataelement-12944
|
|
|
| Id |
prsb03-dataelement-12944 (2019‑11‑20 12:13:29)
|
| Concept inherits from |
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
|
| FHIR |
[JH] This will be dropped from the PRSB information model, as conflicts with description
above
|
|
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Medication change summary cluster
prsb03-dataelement-12945
|
|
|
|
|
Status
prsb03-dataelement-12946
|
|
|
|
|
Indication
prsb03-dataelement-12947
|
|
|
| Id |
prsb03-dataelement-12947 (2019‑11‑20 12:13:29)
|
| Concept inherits from |
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 |
|
|
|
Date of change
prsb03-dataelement-12948
|
|
|
| Id |
prsb03-dataelement-12948 (2019‑11‑20 12:13:29)
|
| Concept inherits from |
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 |
|
|
|
Description of amendment
prsb03-dataelement-12949
|
|
|
| Id |
prsb03-dataelement-12949 (2019‑11‑20 12:13:29)
|
| Concept inherits from |
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 |
|
|
|
Total dose daily quantity
prsb03-dataelement-12950
|
|
|
| Id |
prsb03-dataelement-12950 (2019‑11‑20 12:13:29)
|
| Concept inherits from |
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 |
|
|
|
Person completing record
prsb03-dataelement-12951
|
|
|
|
|
Name
prsb03-dataelement-12952
|
|
|
| Id |
prsb03-dataelement-12952 (2019‑11‑20 12:13:29)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-12953
|
|
|
| Id |
prsb03-dataelement-12953 (2019‑11‑20 12:13:29)
|
| Concept inherits from |
prsb03-dataelement-12886 (2019‑11‑19 17:57:19)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-12954
|
|
|
| Id |
prsb03-dataelement-12954 (2019‑11‑20 12:13:29)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-12955
|
|
|
|
|
Organisation
prsb03-dataelement-12956
|
|
|
|
|
Professional identifier
prsb03-dataelement-12957
|
|
|
| Id |
prsb03-dataelement-12957 (2019‑11‑20 12:13:29)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-12958
|
|
|
| Id |
prsb03-dataelement-12958 (2019‑11‑20 12:13:29)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-12959
|
|
|
| Id |
prsb03-dataelement-12959 (2019‑11‑20 12:13:29)
|
| Concept inherits from |
prsb03-dataelement-12892 (2019‑11‑19 17:57:19)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Location
prsb03-dataelement-10550
|
|
|
| Id |
prsb03-dataelement-10550 (2018‑10‑31) 0.1
|
| Description |
Details of where the Medication was administered |
| Value Domain |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Location in dataset prsb03-dataelement-12597
|
|
|
Date
prsb03-dataelement-10551
|
|
|
| Id |
prsb03-dataelement-10551 (2018‑10‑31) 0.1
|
| Description |
The date on which the Medication was administered |
| Value Domain |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Date in dataset prsb03-dataelement-12598
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Start date/time in dataset prsb03-dataelement-12599
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
This concept is inherited by concept
Authorised date in dataset prsb03-dataelement-12600
This concept is inherited by concept
Authorised date in dataset prsb03-dataelement-12702
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
This concept is inherited by concept
Valid from date in dataset prsb03-dataelement-12601
This concept is inherited by concept
Valid from date in dataset prsb03-dataelement-12704
|
|
|
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.
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
•Prescribed elsewhere
prsb03-dataelement-10629
|
|
|
| Id |
prsb03-dataelement-10629 (2018‑10‑31) 0.1
|
| Description |
Prescribed elsewhere: Medication managed by another organisation |
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
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.
|
|
|
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. |
|
|
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.) |
|
|
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 |
|
|
|
Free text
prsb03-dataelement-13782
|
|
|
|
|
Free text
prsb03-dataelement-13781
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
Clinical Review of Systems
prsb03-dataelement-314
|
|
|
|
|
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.
|
| 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 |
|
|
|
Information and advice given
prsb03-dataelement-315
|
|
|
|
|
Information and advice given
prsb03-dataelement-10215
|
|
|
| Id |
prsb03-dataelement-10215 (2018‑10‑31)
|
 |
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.
|
|
|
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Date
prsb03-dataelement-10216
|
|
|
| Id |
prsb03-dataelement-10216 (2018‑10‑31)
|
| Description |
The date on which the information and advice was given. |
| Value Domain |
|
|
|
Location
prsb03-dataelement-10217
|
|
|
| Id |
prsb03-dataelement-10217 (2018‑10‑31)
|
| Description |
Details of where the information and advice was given. |
| Value Domain |
|
|
|
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 |
|
|
|
Contact for further information
prsb03-dataelement-329
|
|
|
|
|
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.
|
|
|
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 |
|
|
|
Distribution list
prsb03-dataelement-330
|
|
|
|
|
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.
|
|
|
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.
|
| FHIR |
Practitioner.name Patient ..... RelatedPerson..... |
|
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
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).
|
| FHIR |
PractitionerRole.code |
|
| Operationalization |
FHIR value set : -
SDSjobrole
|
| Value Domain |
|
|
|
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. |
| FHIR |
PractitionerRole.code |
|
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
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.
|
| FHIR |
Organization.name Organization.identifier |
|
| Operationalization |
NHS data dictionary : -
Organisation code
|
| Value Domain |
|
| Property |
| min length |
max length |
| 3 |
5 |
|
|
|
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.
|
|
|
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
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 |
| FHIR |
RelatedPerson.relationship |
|
|
|
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 |
|
|
|
Birth Details
prsb03-dataelement-336
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
Birth weight
prsb03-dataelement-10238
|
|
|
|
|
Date & Time of birth
prsb03-dataelement-10239
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Name
prsb03-dataelement-10248
|
|
|
|
|
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 |
|
|
|
Baby Identifier
prsb03-dataelement-10250
|
|
|
|
|
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 |
|
|
|
Birth Outcome
prsb03-dataelement-10252
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
Investigations Requested
prsb03-dataelement-10255
|
|
|
| Id |
prsb03-dataelement-10255 (2018‑10‑31)
|
| Description |
To include any investigations requested including post mortem investigations) |
| Value Domain |
|
|
|
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 |
|
|
|
Put To Breast
prsb03-dataelement-10257
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Demographic History
prsb03-dataelement-361
|
|
|
|
|
Date of birth
prsb03-dataelement-10261
|
|
|
|
|
Gender
prsb03-dataelement-10262
|
|
|
|
|
Patient address
prsb03-dataelement-10263
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
Developmental Skills
prsb03-dataelement-366
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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. |
| FHIR |
Encounter.participant |
|
| Relationship |
|
| Operationalization |
Text |
| Value Domain |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Comments
prsb03-dataelement-10266
|
|
|
| Id |
prsb03-dataelement-10266 (2018‑10‑31)
|
| Description |
Supporting text may be given regarding the developmental skill. |
| Value Domain |
|
|
|
Educational History
prsb03-dataelement-373
|
|
|
|
|
Educational Assessment
prsb03-dataelement-10273
|
|
|
|
|
Educational establishment
prsb03-dataelement-10274
|
|
|
|
|
Type of Educational establishment
prsb03-dataelement-10275
|
|
|
|
|
Type of Special Educational Need
prsb03-dataelement-10276
|
|
|
|
|
Year From
prsb03-dataelement-10277
|
|
|
|
|
Year To
prsb03-dataelement-10278
|
|
|
|
|
Feeding Status
prsb03-dataelement-392
|
|
|
|
|
Date
prsb03-dataelement-10292
|
|
|
|
|
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 |
|
|
|
Feeding concerns
prsb03-dataelement-10294
|
|
|
|
|
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 |
|
|
|
First milk feed
prsb03-dataelement-10296
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
Health and Wellbeing Assessment and Reviews
prsb03-dataelement-399
|
|
|
|
|
Date
prsb03-dataelement-10299
|
|
|
|
|
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 |
|
|
|
New Baby Review
prsb03-dataelement-10301
|
|
|
|
|
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 |
|
|
|
1 Year Review
prsb03-dataelement-10303
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Immunisations
prsb03-dataelement-407
|
|
|
|
|
Batch number
prsb03-dataelement-10307
|
|
|
|
|
Date
prsb03-dataelement-10308
|
|
|
|
|
Dose Amount
prsb03-dataelement-10309
|
|
|
|
|
Dose sequence
prsb03-dataelement-10310
|
|
|
|
|
Indication
prsb03-dataelement-10311
|
|
|
| Id |
prsb03-dataelement-10311 (2018‑10‑31)
|
| Description |
The clinical indication or reason for administering the immunisation |
| Value Domain |
|
|
|
Location
prsb03-dataelement-10312
|
|
|
|
|
Manufacturer
prsb03-dataelement-10313
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
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 |
|
|
|
Route
prsb03-dataelement-10318
|
|
|
|
|
Site
prsb03-dataelement-10319
|
|
|
|
|
Vaccine product
prsb03-dataelement-10320
|
|
|
|
|
Measurements
prsb03-dataelement-421
|
|
|
|
|
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 |
|
|
|
Date
prsb03-dataelement-10322
|
|
|
|
|
Head Circumference
prsb03-dataelement-10323
|
|
|
|
|
Height/Length
prsb03-dataelement-10324
|
|
|
|
|
Location
prsb03-dataelement-10325
|
|
|
|
|
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 |
|
|
|
Weight
prsb03-dataelement-10327
|
|
|
|
|
National Screening Programme
prsb03-dataelement-428
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
•National antenatel screening programme
prsb03-dataelement-10336
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Parent/Guardian/Personal Comment
prsb03-dataelement-442
|
|
|
|
|
Date
prsb03-dataelement-10342
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
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.
|
|
|
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.
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Name
prsb03-dataelement-12168
|
|
|
| Id |
prsb03-dataelement-12168 (2019‑05‑31 16:14:03)
|
| Concept inherits from |
prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
|
|
Role
prsb03-dataelement-12169
|
|
|
| Id |
prsb03-dataelement-12169 (2019‑05‑31 16:14:03)
|
| Concept inherits from |
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 |
|
|
|
Grade
prsb03-dataelement-12170
|
|
|
| Id |
prsb03-dataelement-12170 (2019‑05‑31 16:14:03)
|
| Concept inherits from |
prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Speciality
prsb03-dataelement-12171
|
|
|
|
|
Professional identifier
prsb03-dataelement-12172
|
|
|
| Id |
prsb03-dataelement-12172 (2019‑05‑31 16:14:03)
|
| Concept inherits from |
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 |
|
|
|
Organisation
prsb03-dataelement-12173
|
|
|
|
|
Contact details
prsb03-dataelement-12174
|
|
|
| Id |
prsb03-dataelement-12174 (2019‑05‑31 16:14:03)
|
| Concept inherits from |
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 |
|
|
|
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. |
|
|
Coded value
prsb03-dataelement-13684
|
|
|
|
|
Free text
prsb03-dataelement-13685
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Person completing record
prsb03-dataelement-12175
|
|
|
|
|
Name
prsb03-dataelement-12176
|
|
|
| Id |
prsb03-dataelement-12176 (2019‑05‑31 16:15:32)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-12177
|
|
|
| Id |
prsb03-dataelement-12177 (2019‑05‑31 16:15:32)
|
| Concept inherits from |
prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-12178
|
|
|
| Id |
prsb03-dataelement-12178 (2019‑05‑31 16:15:32)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-12179
|
|
|
|
|
Organisation
prsb03-dataelement-12180
|
|
|
|
|
Professional identifier
prsb03-dataelement-12181
|
|
|
| Id |
prsb03-dataelement-12181 (2019‑05‑31 16:15:32)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-12182
|
|
|
| Id |
prsb03-dataelement-12182 (2019‑05‑31 16:15:32)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-12183
|
|
|
| Id |
prsb03-dataelement-12183 (2019‑05‑31 16:15:32)
|
| Concept inherits from |
prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Special monitoring required
prsb03-dataelement-10440
|
|
|
|
|
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 |
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Escalation plan in dataset prsb03-dataelement-10792
|
|
|
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 |
|
|
|
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 |
|
|
|
Person completing record
prsb03-dataelement-12605
|
|
|
|
|
Name
prsb03-dataelement-12606
|
|
|
| Id |
prsb03-dataelement-12606 (2019‑11‑14 12:35:42)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-12607
|
|
|
| Id |
prsb03-dataelement-12607 (2019‑11‑14 12:35:42)
|
| Concept inherits from |
prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-12608
|
|
|
| Id |
prsb03-dataelement-12608 (2019‑11‑14 12:35:42)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-12609
|
|
|
|
|
Organisation
prsb03-dataelement-12610
|
|
|
|
|
Professional identifier
prsb03-dataelement-12611
|
|
|
| Id |
prsb03-dataelement-12611 (2019‑11‑14 12:35:42)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-12612
|
|
|
| Id |
prsb03-dataelement-12612 (2019‑11‑14 12:35:42)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-12613
|
|
|
| Id |
prsb03-dataelement-12613 (2019‑11‑14 12:35:42)
|
| Concept inherits from |
prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
Senior Reviewing Clinician
prsb03-dataelement-12614
|
|
|
|
|
Name
prsb03-dataelement-12615
|
|
|
| Id |
prsb03-dataelement-12615 (2019‑11‑14 17:14:36)
|
| Concept inherits from |
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 |
|
|
|
Professional identifier
prsb03-dataelement-12616
|
|
|
| Id |
prsb03-dataelement-12616 (2019‑11‑14 17:14:36)
|
| Concept inherits from |
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 |
|
|
|
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 |
|
|
Care planning arrangements
prsb03-dataelement-10791
|
|
|
| Id |
prsb03-dataelement-10791 (2019‑03‑19 18:17:47) 0.1
|
| Concept inherits from |
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 |
|
|
|
Escalation plan
prsb03-dataelement-10792
|
|
|
| Id |
prsb03-dataelement-10792 (2019‑03‑19 18:18:19) 0.1
|
| Concept inherits from |
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 |
|
|
|
Formulation
prsb03-dataelement-10793
|
|
|
| Id |
prsb03-dataelement-10793 (2019‑03‑19 18:19:23) 0.1
|
| Concept inherits from |
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 |
|
|
|
Mental health act or equivalent status
prsb03-dataelement-10794
|
|
|
|
|
Mental capacity assessment
prsb03-dataelement-10795
|
|
|
|
|
Deprivation of Liberty Safeguards or equivalent
prsb03-dataelement-10796
|
|
|
|
|
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 |
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 |
|
|
|
Person and carer concerns expectations and wishes
prsb03-dataelement-292
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
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.
|
| 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 |
|
|
|
Person completing record
prsb03-dataelement-13740
|
|
|
| Id |
prsb03-dataelement-13740 (2020‑09‑25 16:27:48)
|
| Concept inherits from |
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 |
|
|
|
Name
prsb03-dataelement-13741
|
|
|
| Id |
prsb03-dataelement-13741 (2020‑09‑25 16:28:39)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-13742
|
|
|
| Id |
prsb03-dataelement-13742 (2020‑09‑25 16:28:39)
|
| Concept inherits from |
prsb03-dataelement-13054 (2020‑04‑28 19:36:38)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-13743
|
|
|
| Id |
prsb03-dataelement-13743 (2020‑09‑25 16:28:39)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-13744
|
|
|
|
|
Organisation
prsb03-dataelement-13745
|
|
|
|
|
Professional identifier
prsb03-dataelement-13746
|
|
|
| Id |
prsb03-dataelement-13746 (2020‑09‑25 16:28:39)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-13747
|
|
|
| Id |
prsb03-dataelement-13747 (2020‑09‑25 16:28:39)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-13748
|
|
|
| Id |
prsb03-dataelement-13748 (2020‑09‑25 16:28:39)
|
| Concept inherits from |
prsb03-dataelement-13060 (2020‑04‑28 19:36:38)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
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.
|
|
|
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 |
|
|
|
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 |
|
|
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 |
|
|
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.
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
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 |
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Coded value
prsb03-dataelement-13665
|
|
|
|
|
Free text
prsb03-dataelement-13666
|
|
|
|
|
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 |
|
|
|
Name
prsb03-dataelement-12028
|
|
|
| Id |
prsb03-dataelement-12028 (2019‑05‑31 15:30:50)
|
| Concept inherits from |
prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
This concept is inherited by concept
Name in dataset prsb03-dataelement-13045
This concept is inherited by concept
Name in dataset prsb03-dataelement-13182
|
|
|
Role
prsb03-dataelement-12029
|
|
|
| Id |
prsb03-dataelement-12029 (2019‑05‑31 15:30:50)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
This concept is inherited by concept
Role in dataset prsb03-dataelement-13046
This concept is inherited by concept
Role in dataset prsb03-dataelement-13183
|
|
|
Grade
prsb03-dataelement-12030
|
|
|
| Id |
prsb03-dataelement-12030 (2019‑05‑31 15:30:50)
|
| Concept inherits from |
prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
This concept is inherited by concept
Grade in dataset prsb03-dataelement-13047
This concept is inherited by concept
Grade in dataset prsb03-dataelement-13184
|
|
|
Speciality
prsb03-dataelement-12031
|
|
|
| Id |
prsb03-dataelement-12031 (2019‑05‑31 15:30:50)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-13048
This concept is inherited by concept
Speciality in dataset prsb03-dataelement-13185
|
|
|
Professional identifier
prsb03-dataelement-12032
|
|
|
| Id |
prsb03-dataelement-12032 (2019‑05‑31 15:30:50)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
|
|
|
Organisation
prsb03-dataelement-12033
|
|
|
| Id |
prsb03-dataelement-12033 (2019‑05‑31 15:30:50)
|
| Concept inherits from |
prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
|
| Description |
The name of the organisation the professional works for. |
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-13050
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-13187
|
|
|
Contact details
prsb03-dataelement-12034
|
|
|
| Id |
prsb03-dataelement-12034 (2019‑05‑31 15:30:50)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-13051
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-13188
|
|
|
Person completing record
prsb03-dataelement-12035
|
|
|
|
|
Name
prsb03-dataelement-12036
|
|
|
| Id |
prsb03-dataelement-12036 (2019‑05‑31 15:31:27)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-12037
|
|
|
| Id |
prsb03-dataelement-12037 (2019‑05‑31 15:31:27)
|
| Concept inherits from |
prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-12038
|
|
|
| Id |
prsb03-dataelement-12038 (2019‑05‑31 15:31:27)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-12039
|
|
|
|
|
Organisation
prsb03-dataelement-12040
|
|
|
|
|
Professional identifier
prsb03-dataelement-12041
|
|
|
| Id |
prsb03-dataelement-12041 (2019‑05‑31 15:31:27)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-12042
|
|
|
| Id |
prsb03-dataelement-12042 (2019‑05‑31 15:31:27)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-12043
|
|
|
| Id |
prsb03-dataelement-12043 (2019‑05‑31 15:31:27)
|
| Concept inherits from |
prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
Person completing record
prsb03-dataelement-10840
|
|
|
| Id |
prsb03-dataelement-10840 (2019‑03‑27 16:19:24)
|
| Concept inherits from |
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 |
|
|
|
Contingency plans
prsb03-dataelement-469
|
|
|
|
|
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 |
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
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 |
|
|
|
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 |
|
|
|
Location
prsb03-dataelement-12268
|
|
|
| Id |
prsb03-dataelement-12268 (2019‑05‑31 16:39:59)
|
| Description |
The location where the advanced statement was made. |
| Relationship |
|
|
|
Coded value
prsb03-dataelement-13698
|
|
|
|
|
Free text
prsb03-dataelement-13699
|
|
|
|
|
Advance statement
prsb03-dataelement-13695
|
|
|
|
|
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 |
|
|
|
Free text
prsb03-dataelement-13697
|
|
|
|
|
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 |
|
|
|
Performing professional
prsb03-dataelement-12269
|
|
|
| Id |
prsb03-dataelement-12269 (2019‑05‑31 16:40:44)
|
| Description |
The professional who made the advance statement. |
| Relationship |
|
|
|
Name
prsb03-dataelement-12270
|
|
|
| Id |
prsb03-dataelement-12270 (2019‑05‑31 16:41:01)
|
| Concept inherits from |
prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
|
|
Role
prsb03-dataelement-12271
|
|
|
| Id |
prsb03-dataelement-12271 (2019‑05‑31 16:41:01)
|
| Concept inherits from |
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 |
|
|
|
Grade
prsb03-dataelement-12272
|
|
|
| Id |
prsb03-dataelement-12272 (2019‑05‑31 16:41:01)
|
| Concept inherits from |
prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Speciality
prsb03-dataelement-12273
|
|
|
|
|
Professional identifier
prsb03-dataelement-12274
|
|
|
| Id |
prsb03-dataelement-12274 (2019‑05‑31 16:41:01)
|
| Concept inherits from |
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 |
|
|
|
Organisation
prsb03-dataelement-12275
|
|
|
|
|
Contact details
prsb03-dataelement-12276
|
|
|
| Id |
prsb03-dataelement-12276 (2019‑05‑31 16:41:01)
|
| Concept inherits from |
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 |
|
|
|
Person completing record
prsb03-dataelement-12277
|
|
|
|
|
Name
prsb03-dataelement-12278
|
|
|
| Id |
prsb03-dataelement-12278 (2019‑05‑31 16:42:15)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-12279
|
|
|
| Id |
prsb03-dataelement-12279 (2019‑05‑31 16:42:15)
|
| Concept inherits from |
prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-12280
|
|
|
| Id |
prsb03-dataelement-12280 (2019‑05‑31 16:42:15)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-12281
|
|
|
|
|
Organisation
prsb03-dataelement-12282
|
|
|
|
|
Professional identifier
prsb03-dataelement-12283
|
|
|
| Id |
prsb03-dataelement-12283 (2019‑05‑31 16:42:15)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-12284
|
|
|
| Id |
prsb03-dataelement-12284 (2019‑05‑31 16:42:15)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-12285
|
|
|
| Id |
prsb03-dataelement-12285 (2019‑05‑31 16:42:15)
|
| Concept inherits from |
prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Coping strategies
prsb03-dataelement-13850
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Location
prsb03-dataelement-12079
|
|
|
| Id |
prsb03-dataelement-12079 (2019‑05‑31 15:39:45)
|
| Description |
The location where the contingency plan was prepared. |
| Relationship |
|
|
|
Coded value
prsb03-dataelement-13667
|
|
|
|
|
Free text
prsb03-dataelement-13668
|
|
|
|
|
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 |
|
|
|
Performing professional
prsb03-dataelement-12045
|
|
|
| Id |
prsb03-dataelement-12045 (2019‑05‑31 15:33:20)
|
| Description |
The professional who prepared the contingency plans. |
| Relationship |
|
|
|
Name
prsb03-dataelement-12046
|
|
|
| Id |
prsb03-dataelement-12046 (2019‑05‑31 15:33:38)
|
| Concept inherits from |
prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
|
|
Role
prsb03-dataelement-12047
|
|
|
| Id |
prsb03-dataelement-12047 (2019‑05‑31 15:33:38)
|
| Concept inherits from |
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 |
|
|
|
Grade
prsb03-dataelement-12048
|
|
|
| Id |
prsb03-dataelement-12048 (2019‑05‑31 15:33:38)
|
| Concept inherits from |
prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Speciality
prsb03-dataelement-12049
|
|
|
|
|
Professional identifier
prsb03-dataelement-12050
|
|
|
| Id |
prsb03-dataelement-12050 (2019‑05‑31 15:33:38)
|
| Concept inherits from |
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 |
|
|
|
Organisation
prsb03-dataelement-12051
|
|
|
|
|
Contact details
prsb03-dataelement-12052
|
|
|
| Id |
prsb03-dataelement-12052 (2019‑05‑31 15:33:38)
|
| Concept inherits from |
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 |
|
|
|
Person completing record
prsb03-dataelement-12053
|
|
|
|
|
Name
prsb03-dataelement-12054
|
|
|
| Id |
prsb03-dataelement-12054 (2019‑05‑31 15:34:15)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-12055
|
|
|
| Id |
prsb03-dataelement-12055 (2019‑05‑31 15:34:15)
|
| Concept inherits from |
prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-12056
|
|
|
| Id |
prsb03-dataelement-12056 (2019‑05‑31 15:34:15)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-12057
|
|
|
|
|
Organisation
prsb03-dataelement-12058
|
|
|
|
|
Professional identifier
prsb03-dataelement-12059
|
|
|
| Id |
prsb03-dataelement-12059 (2019‑05‑31 15:34:15)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-12060
|
|
|
| Id |
prsb03-dataelement-12060 (2019‑05‑31 15:34:15)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-12061
|
|
|
| Id |
prsb03-dataelement-12061 (2019‑05‑31 15:34:15)
|
| Concept inherits from |
prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
Outstanding Issues
prsb03-dataelement-478
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
Person handing over
prsb03-dataelement-480
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
Grade
prsb03-dataelement-10382
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
Person receiving handover
prsb03-dataelement-485
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
Grade
prsb03-dataelement-10387
|
|
|
|
|
Specialty
prsb03-dataelement-10388
|
|
|
| Id |
prsb03-dataelement-10388 (2018‑10‑31) 0.1
|
| Description |
The specialty of the person receiving the handover |
| Value Domain |
|
|
|
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 |
|
|
|
Handover Details
prsb03-dataelement-490
|
|
|
|
|
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 |
|
|
|
Planned patient location
prsb03-dataelement-10391
|
|
|
|
|
Date of admission
prsb03-dataelement-10392
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Date of decision to handover
prsb03-dataelement-10397
|
|
|
|
|
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 |
|
|
|
Date handover accepted
prsb03-dataelement-10399
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
Additional support plans
prsb03-dataelement-502
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
Coded value
prsb03-dataelement-13722
|
|
|
|
|
Free text
prsb03-dataelement-13723
|
|
|
|
|
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 |
|
|
|
Name
prsb03-dataelement-12063
|
|
|
| Id |
prsb03-dataelement-12063 (2019‑05‑31 15:36:35)
|
| Concept inherits from |
prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
|
|
Role
prsb03-dataelement-12064
|
|
|
| Id |
prsb03-dataelement-12064 (2019‑05‑31 15:36:35)
|
| Concept inherits from |
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 |
|
|
|
Grade
prsb03-dataelement-12065
|
|
|
| Id |
prsb03-dataelement-12065 (2019‑05‑31 15:36:35)
|
| Concept inherits from |
prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Speciality
prsb03-dataelement-12066
|
|
|
|
|
Professional identifier
prsb03-dataelement-12067
|
|
|
| Id |
prsb03-dataelement-12067 (2019‑05‑31 15:36:35)
|
| Concept inherits from |
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 |
|
|
|
Organisation
prsb03-dataelement-12068
|
|
|
|
|
Contact details
prsb03-dataelement-12069
|
|
|
| Id |
prsb03-dataelement-12069 (2019‑05‑31 15:36:35)
|
| Concept inherits from |
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 |
|
|
|
Person completing record
prsb03-dataelement-12070
|
|
|
|
|
Name
prsb03-dataelement-12071
|
|
|
| Id |
prsb03-dataelement-12071 (2019‑05‑31 15:37:13)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-12072
|
|
|
| Id |
prsb03-dataelement-12072 (2019‑05‑31 15:37:13)
|
| Concept inherits from |
prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-12073
|
|
|
| Id |
prsb03-dataelement-12073 (2019‑05‑31 15:37:13)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-12074
|
|
|
|
|
Organisation
prsb03-dataelement-12075
|
|
|
|
|
Professional identifier
prsb03-dataelement-12076
|
|
|
| Id |
prsb03-dataelement-12076 (2019‑05‑31 15:37:13)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-12077
|
|
|
| Id |
prsb03-dataelement-12077 (2019‑05‑31 15:37:13)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-12078
|
|
|
| Id |
prsb03-dataelement-12078 (2019‑05‑31 15:37:13)
|
| Concept inherits from |
prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
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.
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
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 |
|
|
|
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 |
|
|
|
Planned review date
prsb03-dataelement-10770
|
|
|
| Id |
prsb03-dataelement-10770 (2019‑03‑19 13:40:30) 0.1
|
| Concept inherits from |
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Coded value
prsb03-dataelement-13689
|
|
|
|
|
Free text
prsb03-dataelement-13690
|
|
|
|
|
Cardio-pulmonary resuscitation (CPR) decision
prsb03-dataelement-13686
|
|
|
|
|
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 |
|
|
|
Free text
prsb03-dataelement-13688
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Name
prsb03-dataelement-12213
|
|
|
| Id |
prsb03-dataelement-12213 (2019‑05‑31 16:30:28)
|
| Concept inherits from |
prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
|
|
Role
prsb03-dataelement-12214
|
|
|
| Id |
prsb03-dataelement-12214 (2019‑05‑31 16:30:28)
|
| Concept inherits from |
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 |
|
|
|
Grade
prsb03-dataelement-12215
|
|
|
| Id |
prsb03-dataelement-12215 (2019‑05‑31 16:30:28)
|
| Concept inherits from |
prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Speciality
prsb03-dataelement-12216
|
|
|
|
|
Professional identifier
prsb03-dataelement-12217
|
|
|
| Id |
prsb03-dataelement-12217 (2019‑05‑31 16:30:28)
|
| Concept inherits from |
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 |
|
|
|
Organisation
prsb03-dataelement-12218
|
|
|
|
|
Contact details
prsb03-dataelement-12219
|
|
|
| Id |
prsb03-dataelement-12219 (2019‑05‑31 16:30:28)
|
| Concept inherits from |
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 |
|
|
|
Person completing record
prsb03-dataelement-12220
|
|
|
|
|
Name
prsb03-dataelement-12221
|
|
|
| Id |
prsb03-dataelement-12221 (2019‑05‑31 16:31:04)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-12222
|
|
|
| Id |
prsb03-dataelement-12222 (2019‑05‑31 16:31:04)
|
| Concept inherits from |
prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-12223
|
|
|
| Id |
prsb03-dataelement-12223 (2019‑05‑31 16:31:04)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-12224
|
|
|
|
|
Organisation
prsb03-dataelement-12225
|
|
|
|
|
Professional identifier
prsb03-dataelement-12226
|
|
|
| Id |
prsb03-dataelement-12226 (2019‑05‑31 16:31:04)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-12227
|
|
|
| Id |
prsb03-dataelement-12227 (2019‑05‑31 16:31:04)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-12228
|
|
|
| Id |
prsb03-dataelement-12228 (2019‑05‑31 16:31:04)
|
| Concept inherits from |
prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
Individual requirement
prsb03-dataelement-10772
|
|
|
| Id |
prsb03-dataelement-10772 (2019‑03‑19 17:03:23)
|
| Concept inherits from |
prsb03-dataelement-10060 (2018‑10‑31)
|
| Description |
Individual requirement that a person has. These may be communication, cultural, cognitive
or mobility needs.
|
| 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 |
|
|
|
Relevant contacts
prsb03-dataelement-10773
|
|
|
| Id |
prsb03-dataelement-10773 (2019‑03‑19 17:07:45) 0.1
|
| Concept inherits from |
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.
|
|
|
| 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 |
|
|
|
Estimated prognosis
prsb03-dataelement-10774
|
|
|
| Id |
prsb03-dataelement-10774 (2019‑03‑19 17:09:08)
|
| Concept inherits from |
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 |
|
|
|
Estimated prognosis
prsb03-dataelement-10745
|
|
|
|
|
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 |
|
|
|
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 |
|
|
Coded value
prsb03-dataelement-13703
|
|
|
|
|
Free text
prsb03-dataelement-13704
|
|
|
|
|
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 |
|
|
|
Performing professional
prsb03-dataelement-12231
|
|
|
| Id |
prsb03-dataelement-12231 (2019‑05‑31 16:33:17)
|
| Description |
The professional who made the estimated prognosis. |
| Relationship |
|
|
|
Name
prsb03-dataelement-12232
|
|
|
| Id |
prsb03-dataelement-12232 (2019‑05‑31 16:33:33)
|
| Concept inherits from |
prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
|
|
Role
prsb03-dataelement-12233
|
|
|
| Id |
prsb03-dataelement-12233 (2019‑05‑31 16:33:33)
|
| Concept inherits from |
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 |
|
|
|
Grade
prsb03-dataelement-12234
|
|
|
| Id |
prsb03-dataelement-12234 (2019‑05‑31 16:33:33)
|
| Concept inherits from |
prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Speciality
prsb03-dataelement-12235
|
|
|
|
|
Professional identifier
prsb03-dataelement-12236
|
|
|
| Id |
prsb03-dataelement-12236 (2019‑05‑31 16:33:33)
|
| Concept inherits from |
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 |
|
|
|
Organisation
prsb03-dataelement-12237
|
|
|
|
|
Contact details
prsb03-dataelement-12238
|
|
|
| Id |
prsb03-dataelement-12238 (2019‑05‑31 16:33:33)
|
| Concept inherits from |
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 |
|
|
|
Person completing record
prsb03-dataelement-12239
|
|
|
|
|
Name
prsb03-dataelement-12240
|
|
|
| Id |
prsb03-dataelement-12240 (2019‑05‑31 16:34:04)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-12241
|
|
|
| Id |
prsb03-dataelement-12241 (2019‑05‑31 16:34:04)
|
| Concept inherits from |
prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-12242
|
|
|
| Id |
prsb03-dataelement-12242 (2019‑05‑31 16:34:04)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-12243
|
|
|
|
|
Organisation
prsb03-dataelement-12244
|
|
|
|
|
Professional identifier
prsb03-dataelement-12245
|
|
|
| Id |
prsb03-dataelement-12245 (2019‑05‑31 16:34:04)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-12246
|
|
|
| Id |
prsb03-dataelement-12246 (2019‑05‑31 16:34:04)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-12247
|
|
|
| Id |
prsb03-dataelement-12247 (2019‑05‑31 16:34:04)
|
| Concept inherits from |
prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
Coded value
prsb03-dataelement-13693
|
|
|
|
|
Free text
prsb03-dataelement-13694
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
Name
prsb03-dataelement-12251
|
|
|
| Id |
prsb03-dataelement-12251 (2019‑05‑31 16:37:48)
|
| Concept inherits from |
prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
|
|
Role
prsb03-dataelement-12252
|
|
|
| Id |
prsb03-dataelement-12252 (2019‑05‑31 16:37:48)
|
| Concept inherits from |
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 |
|
|
|
Grade
prsb03-dataelement-12253
|
|
|
| Id |
prsb03-dataelement-12253 (2019‑05‑31 16:37:48)
|
| Concept inherits from |
prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Speciality
prsb03-dataelement-12254
|
|
|
|
|
Professional identifier
prsb03-dataelement-12255
|
|
|
| Id |
prsb03-dataelement-12255 (2019‑05‑31 16:37:48)
|
| Concept inherits from |
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 |
|
|
|
Organisation
prsb03-dataelement-12256
|
|
|
|
|
Contact details
prsb03-dataelement-12257
|
|
|
| Id |
prsb03-dataelement-12257 (2019‑05‑31 16:37:48)
|
| Concept inherits from |
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 |
|
|
|
Person completing record
prsb03-dataelement-12258
|
|
|
|
|
Name
prsb03-dataelement-12259
|
|
|
| Id |
prsb03-dataelement-12259 (2019‑05‑31 16:38:20)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-12260
|
|
|
| Id |
prsb03-dataelement-12260 (2019‑05‑31 16:38:20)
|
| Concept inherits from |
prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-12261
|
|
|
| Id |
prsb03-dataelement-12261 (2019‑05‑31 16:38:20)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-12262
|
|
|
|
|
Organisation
prsb03-dataelement-12263
|
|
|
|
|
Professional identifier
prsb03-dataelement-12264
|
|
|
| Id |
prsb03-dataelement-12264 (2019‑05‑31 16:38:20)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-12265
|
|
|
| Id |
prsb03-dataelement-12265 (2019‑05‑31 16:38:20)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-12266
|
|
|
| Id |
prsb03-dataelement-12266 (2019‑05‑31 16:38:20)
|
| Concept inherits from |
prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
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 |
|
|
|
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 |
|
|
|
Anticipatory actions
prsb03-dataelement-10786
|
|
|
|
|
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 |
|
|
|
Location
prsb03-dataelement-12287
|
|
|
| Id |
prsb03-dataelement-12287 (2019‑05‑31 16:49:03)
|
| Description |
The location where the anticipatory actions were identified. |
| Relationship |
|
|
|
Coded value
prsb03-dataelement-13701
|
|
|
|
|
Free text
prsb03-dataelement-13702
|
|
|
|
|
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 |
|
|
|
Performing professional
prsb03-dataelement-12288
|
|
|
| Id |
prsb03-dataelement-12288 (2019‑05‑31 16:49:45)
|
| Description |
The professional who identified the anticipatory actions. |
| Relationship |
|
|
|
Name
prsb03-dataelement-12289
|
|
|
| Id |
prsb03-dataelement-12289 (2019‑05‑31 16:50:03)
|
| Concept inherits from |
prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
|
|
Role
prsb03-dataelement-12290
|
|
|
| Id |
prsb03-dataelement-12290 (2019‑05‑31 16:50:03)
|
| Concept inherits from |
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 |
|
|
|
Grade
prsb03-dataelement-12291
|
|
|
| Id |
prsb03-dataelement-12291 (2019‑05‑31 16:50:03)
|
| Concept inherits from |
prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Speciality
prsb03-dataelement-12292
|
|
|
|
|
Professional identifier
prsb03-dataelement-12293
|
|
|
| Id |
prsb03-dataelement-12293 (2019‑05‑31 16:50:03)
|
| Concept inherits from |
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 |
|
|
|
Organisation
prsb03-dataelement-12294
|
|
|
|
|
Contact details
prsb03-dataelement-12295
|
|
|
| Id |
prsb03-dataelement-12295 (2019‑05‑31 16:50:03)
|
| Concept inherits from |
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 |
|
|
|
Person completing record
prsb03-dataelement-12296
|
|
|
|
|
Name
prsb03-dataelement-12297
|
|
|
| Id |
prsb03-dataelement-12297 (2019‑05‑31 16:50:40)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-12298
|
|
|
| Id |
prsb03-dataelement-12298 (2019‑05‑31 16:50:40)
|
| Concept inherits from |
prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-12299
|
|
|
| Id |
prsb03-dataelement-12299 (2019‑05‑31 16:50:40)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-12300
|
|
|
|
|
Organisation
prsb03-dataelement-12301
|
|
|
|
|
Professional identifier
prsb03-dataelement-12302
|
|
|
| Id |
prsb03-dataelement-12302 (2019‑05‑31 16:50:40)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-12303
|
|
|
| Id |
prsb03-dataelement-12303 (2019‑05‑31 16:50:40)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-12304
|
|
|
| Id |
prsb03-dataelement-12304 (2019‑05‑31 16:50:40)
|
| Concept inherits from |
prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Coded value
prsb03-dataelement-13708
|
|
|
|
|
Free text
prsb03-dataelement-13709
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
Name
prsb03-dataelement-12308
|
|
|
| Id |
prsb03-dataelement-12308 (2019‑05‑31 16:53:59)
|
| Concept inherits from |
prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
|
|
Role
prsb03-dataelement-12309
|
|
|
| Id |
prsb03-dataelement-12309 (2019‑05‑31 16:53:59)
|
| Concept inherits from |
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 |
|
|
|
Grade
prsb03-dataelement-12310
|
|
|
| Id |
prsb03-dataelement-12310 (2019‑05‑31 16:53:59)
|
| Concept inherits from |
prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Speciality
prsb03-dataelement-12311
|
|
|
|
|
Professional identifier
prsb03-dataelement-12312
|
|
|
| Id |
prsb03-dataelement-12312 (2019‑05‑31 16:53:59)
|
| Concept inherits from |
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 |
|
|
|
Organisation
prsb03-dataelement-12313
|
|
|
|
|
Contact details
prsb03-dataelement-12314
|
|
|
| Id |
prsb03-dataelement-12314 (2019‑05‑31 16:53:59)
|
| Concept inherits from |
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 |
|
|
|
Person completing record
prsb03-dataelement-12315
|
|
|
|
|
Name
prsb03-dataelement-12316
|
|
|
| Id |
prsb03-dataelement-12316 (2019‑05‑31 16:54:34)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-12317
|
|
|
| Id |
prsb03-dataelement-12317 (2019‑05‑31 16:54:34)
|
| Concept inherits from |
prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-12318
|
|
|
| Id |
prsb03-dataelement-12318 (2019‑05‑31 16:54:34)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-12319
|
|
|
|
|
Organisation
prsb03-dataelement-12320
|
|
|
|
|
Professional identifier
prsb03-dataelement-12321
|
|
|
| Id |
prsb03-dataelement-12321 (2019‑05‑31 16:54:34)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-12322
|
|
|
| Id |
prsb03-dataelement-12322 (2019‑05‑31 16:54:34)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-12323
|
|
|
| Id |
prsb03-dataelement-12323 (2019‑05‑31 16:54:34)
|
| Concept inherits from |
prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
Advance decision to refuse treatment (ADRT)
prsb03-dataelement-10778
|
|
|
|
|
Lasting power of attorney for personal welfare or court-appointed deputy (or equivalent)
prsb03-dataelement-10779
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Coded value
prsb03-dataelement-13713
|
|
|
|
|
Free text
prsb03-dataelement-13714
|
|
|
|
|
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. |
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Name of the place in dataset prsb03-dataelement-13717
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Type of place in dataset prsb03-dataelement-13718
|
|
|
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 |
|
|
|
Name of the place
prsb03-dataelement-13717
|
|
|
|
|
Type of place
prsb03-dataelement-13718
|
|
|
| Id |
prsb03-dataelement-13718 (2020‑09‑10 16:33:46)
|
| Concept inherits from |
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 |
|
|
|
Preferred place of death
prsb03-dataelement-13715
|
|
|
| Id |
prsb03-dataelement-13715 (2020‑09‑10 16:30:08) 0.1
|
| Concept inherits from |
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 |
|
|
|
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 |
|
|
|
Name
prsb03-dataelement-12327
|
|
|
| Id |
prsb03-dataelement-12327 (2019‑05‑31 16:57:14)
|
| Concept inherits from |
prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
|
|
Role
prsb03-dataelement-12328
|
|
|
| Id |
prsb03-dataelement-12328 (2019‑05‑31 16:57:14)
|
| Concept inherits from |
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 |
|
|
|
Grade
prsb03-dataelement-12329
|
|
|
| Id |
prsb03-dataelement-12329 (2019‑05‑31 16:57:14)
|
| Concept inherits from |
prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Speciality
prsb03-dataelement-12330
|
|
|
|
|
Professional identifier
prsb03-dataelement-12331
|
|
|
| Id |
prsb03-dataelement-12331 (2019‑05‑31 16:57:14)
|
| Concept inherits from |
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 |
|
|
|
Organisation
prsb03-dataelement-12332
|
|
|
|
|
Contact details
prsb03-dataelement-12333
|
|
|
| Id |
prsb03-dataelement-12333 (2019‑05‑31 16:57:14)
|
| Concept inherits from |
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 |
|
|
|
Person completing record
prsb03-dataelement-12334
|
|
|
|
|
Name
prsb03-dataelement-12335
|
|
|
| Id |
prsb03-dataelement-12335 (2019‑05‑31 16:57:52)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-12336
|
|
|
| Id |
prsb03-dataelement-12336 (2019‑05‑31 16:57:52)
|
| Concept inherits from |
prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-12337
|
|
|
| Id |
prsb03-dataelement-12337 (2019‑05‑31 16:57:52)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-12338
|
|
|
|
|
Organisation
prsb03-dataelement-12339
|
|
|
|
|
Professional identifier
prsb03-dataelement-12340
|
|
|
| Id |
prsb03-dataelement-12340 (2019‑05‑31 16:57:52)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-12341
|
|
|
| Id |
prsb03-dataelement-12341 (2019‑05‑31 16:57:52)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-12342
|
|
|
| Id |
prsb03-dataelement-12342 (2019‑05‑31 16:57:52)
|
| Concept inherits from |
prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
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 |
|
|
Date
prsb03-dataelement-12343
|
|
|
| Id |
prsb03-dataelement-12343 (2019‑05‑31 16:58:33) 0.1
|
| Concept inherits from |
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 |
|
|
|
Location
prsb03-dataelement-12344
|
|
|
|
|
Performing professional
prsb03-dataelement-12345
|
|
|
|
|
Name
prsb03-dataelement-12346
|
|
|
| Id |
prsb03-dataelement-12346 (2019‑05‑31 17:00:07) 0.1
|
| Concept inherits from |
prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
|
|
Role
prsb03-dataelement-12347
|
|
|
| Id |
prsb03-dataelement-12347 (2019‑05‑31 17:00:07) 0.1
|
| Concept inherits from |
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 |
|
|
|
Grade
prsb03-dataelement-12348
|
|
|
| Id |
prsb03-dataelement-12348 (2019‑05‑31 17:00:07) 0.1
|
| Concept inherits from |
prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Speciality
prsb03-dataelement-12349
|
|
|
|
|
Professional identifier
prsb03-dataelement-12350
|
|
|
| Id |
prsb03-dataelement-12350 (2019‑05‑31 17:00:07) 0.1
|
| Concept inherits from |
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 |
|
|
|
Organisation
prsb03-dataelement-12351
|
|
|
|
|
Contact details
prsb03-dataelement-12352
|
|
|
| Id |
prsb03-dataelement-12352 (2019‑05‑31 17:00:07) 0.1
|
| Concept inherits from |
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 |
|
|
|
Person completing record
prsb03-dataelement-12353
|
|
|
|
|
Name
prsb03-dataelement-12354
|
|
|
| Id |
prsb03-dataelement-12354 (2019‑05‑31 17:00:42) 0.1
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-12355
|
|
|
| Id |
prsb03-dataelement-12355 (2019‑05‑31 17:00:42) 0.1
|
| Concept inherits from |
prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-12356
|
|
|
| Id |
prsb03-dataelement-12356 (2019‑05‑31 17:00:42) 0.1
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-12357
|
|
|
|
|
Organisation
prsb03-dataelement-12358
|
|
|
|
|
Professional identifier
prsb03-dataelement-12359
|
|
|
| Id |
prsb03-dataelement-12359 (2019‑05‑31 17:00:42) 0.1
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-12360
|
|
|
| Id |
prsb03-dataelement-12360 (2019‑05‑31 17:00:42) 0.1
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-12361
|
|
|
| Id |
prsb03-dataelement-12361 (2019‑05‑31 17:00:42) 0.1
|
| Concept inherits from |
prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Coded value
prsb03-dataelement-13720
|
|
|
|
|
Free text
prsb03-dataelement-13721
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
Name
prsb03-dataelement-12365
|
|
|
| Id |
prsb03-dataelement-12365 (2019‑05‑31 17:03:28)
|
| Concept inherits from |
prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
|
|
Role
prsb03-dataelement-12366
|
|
|
| Id |
prsb03-dataelement-12366 (2019‑05‑31 17:03:28)
|
| Concept inherits from |
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 |
|
|
|
Grade
prsb03-dataelement-12367
|
|
|
| Id |
prsb03-dataelement-12367 (2019‑05‑31 17:03:28)
|
| Concept inherits from |
prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Speciality
prsb03-dataelement-12368
|
|
|
|
|
Professional identifier
prsb03-dataelement-12369
|
|
|
| Id |
prsb03-dataelement-12369 (2019‑05‑31 17:03:28)
|
| Concept inherits from |
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 |
|
|
|
Organisation
prsb03-dataelement-12370
|
|
|
|
|
Contact details
prsb03-dataelement-12371
|
|
|
| Id |
prsb03-dataelement-12371 (2019‑05‑31 17:03:28)
|
| Concept inherits from |
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 |
|
|
|
Person completing record
prsb03-dataelement-12372
|
|
|
|
|
Name
prsb03-dataelement-12373
|
|
|
| Id |
prsb03-dataelement-12373 (2019‑05‑31 17:04:03)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-12374
|
|
|
| Id |
prsb03-dataelement-12374 (2019‑05‑31 17:04:03)
|
| Concept inherits from |
prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-12375
|
|
|
| Id |
prsb03-dataelement-12375 (2019‑05‑31 17:04:03)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-12376
|
|
|
|
|
Organisation
prsb03-dataelement-12377
|
|
|
|
|
Professional identifier
prsb03-dataelement-12378
|
|
|
| Id |
prsb03-dataelement-12378 (2019‑05‑31 17:04:03)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-12379
|
|
|
| Id |
prsb03-dataelement-12379 (2019‑05‑31 17:04:03)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-12380
|
|
|
| Id |
prsb03-dataelement-12380 (2019‑05‑31 17:04:03)
|
| Concept inherits from |
prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
Actual place of death
prsb03-dataelement-10782
|
|
|
| Id |
prsb03-dataelement-10782 (2019‑03‑19 17:17:13) 0.1
|
| Concept inherits from |
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 |
|
|
|
Date of death
prsb03-dataelement-10783
|
|
|
| Id |
prsb03-dataelement-10783 (2019‑03‑19 17:17:37) 0.1
|
| Concept inherits from |
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.
|
|
|
| Operationalization |
Date and time |
| Value Domain |
|
|
|
Date this plan was last updated
prsb03-dataelement-10788
|
|
|
| Id |
prsb03-dataelement-10788 (2019‑03‑19 18:00:25) 0.1
|
| Concept inherits from |
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 |
|
|
|
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 |
|
|
|
Cardio-pulmonary resuscitation (CPR) decision
prsb03-dataelement-10744
|
|
|
| Id |
prsb03-dataelement-10744 (2019‑03‑07 11:07:59)
|
| Concept inherits from |
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 |
|
|
|
After death
prsb03-dataelement-309
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
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 |
|
|
|
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.
|
|
|
| Operationalization |
Date and time |
| Value Domain |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Date of death in dataset prsb03-dataelement-10783
|
|
|
Crisis Care Plan
prsb03-dataelement-300
|
|
|
|
|
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 |
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Personal comment/plan
prsb03-dataelement-581
|
|
|
|
|
Date
prsb03-dataelement-10481
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Pregnancy episode details
prsb03-dataelement-585
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
Maternity Episode Start Date
prsb03-dataelement-10487
|
|
|
|
|
Maternity Episode End Date
prsb03-dataelement-10488
|
|
|
|
|
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 |
|
|
|
Pregnancy outcome delivery and birth
prsb03-dataelement-590
|
|
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Date in dataset prsb03-dataelement-10829
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Location in dataset prsb03-dataelement-10830
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Pregnancy Outcome
prsb03-dataelement-10493
|
|
|
| Id |
prsb03-dataelement-10493 (2018‑10‑31)
|
| Description |
The pregnancy outcome of each fetus |
| Value Domain |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Pregnancy Outcome in dataset prsb03-dataelement-10828
|
|
|
•Birth
prsb03-dataelement-10494
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Date and time pushing commenced
prsb03-dataelement-10500
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
Birth Attendants
prsb03-dataelement-10503
|
|
|
|
|
Ruptured Membranes Date/Time
prsb03-dataelement-10504
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Delivery Decision Date/Time
prsb03-dataelement-10508
|
|
|
|
|
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 |
|
|
|
Reason for delivery decision
prsb03-dataelement-10510
|
|
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Delayed Cord Clamping/duration
prsb03-dataelement-10516
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Placenta Disposal
prsb03-dataelement-10521
|
|
|
|
|
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 |
|
|
|
Umbilical Cord Number of Vessels
prsb03-dataelement-10523
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
Scan details
prsb03-dataelement-626
|
|
|
|
|
Date
prsb03-dataelement-10526
|
|
|
|
|
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 |
|
|
|
Location
prsb03-dataelement-10528
|
|
|
|
|
Scan
prsb03-dataelement-10529
|
|
|
|
|
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 |
|
|
|
Comment
prsb03-dataelement-10531
|
|
|
|
|
Professional comment
prsb03-dataelement-632
|
|
|
|
|
Date
prsb03-dataelement-10532
|
|
|
| Id |
prsb03-dataelement-10532 (2018‑10‑31)
|
| Description |
The date on which the professional summary/comment was recorded |
| Value Domain |
|
|
|
Location
prsb03-dataelement-10533
|
|
|
| Id |
prsb03-dataelement-10533 (2018‑10‑31)
|
| Description |
The location where the professional summary/comment was recorded. |
| Value Domain |
|
|
|
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 |
|
|
|
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 |
|
|
|
Documents (including correspondence and images)
prsb03-dataelement-10820
|
|
|
|
|
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.
|
|
|
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 |
|
|
|
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 |
|
|
|
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. |
|
|
Name
prsb03-dataelement-12423
|
|
|
| Id |
prsb03-dataelement-12423 (2019‑06‑13 15:10:21)
|
| Concept inherits from |
prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
|
|
Role
prsb03-dataelement-12424
|
|
|
| Id |
prsb03-dataelement-12424 (2019‑06‑13 15:10:21)
|
| Concept inherits from |
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 |
|
|
|
Grade
prsb03-dataelement-12425
|
|
|
| Id |
prsb03-dataelement-12425 (2019‑06‑13 15:10:21)
|
| Concept inherits from |
prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Speciality
prsb03-dataelement-12426
|
|
|
|
|
Professional identifier
prsb03-dataelement-12427
|
|
|
| Id |
prsb03-dataelement-12427 (2019‑06‑13 15:10:21)
|
| Concept inherits from |
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 |
|
|
|
Organisation
prsb03-dataelement-12428
|
|
|
|
|
Contact details
prsb03-dataelement-12429
|
|
|
| Id |
prsb03-dataelement-12429 (2019‑06‑13 15:10:21)
|
| Concept inherits from |
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 |
|
|
|
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 |
|
|
|
Confidentiality
prsb03-dataelement-10942
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Person completing record
prsb03-dataelement-12430
|
|
|
|
|
Name
prsb03-dataelement-12431
|
|
|
| Id |
prsb03-dataelement-12431 (2019‑06‑13 15:22:28)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-12432
|
|
|
| Id |
prsb03-dataelement-12432 (2019‑06‑13 15:22:28)
|
| Concept inherits from |
prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-12433
|
|
|
| Id |
prsb03-dataelement-12433 (2019‑06‑13 15:22:28)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-12434
|
|
|
|
|
Organisation
prsb03-dataelement-12435
|
|
|
|
|
Professional identifier
prsb03-dataelement-12436
|
|
|
| Id |
prsb03-dataelement-12436 (2019‑06‑13 15:22:28)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-12437
|
|
|
| Id |
prsb03-dataelement-12437 (2019‑06‑13 15:22:28)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-12438
|
|
|
| Id |
prsb03-dataelement-12438 (2019‑06‑13 15:22:28)
|
| Concept inherits from |
prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
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)|
|
|
|
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 |
|
|
|
Free text
prsb03-dataelement-13750
|
|
|
|
|
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 |
|
|
|
Additional information required for images.
prsb03-dataelement-12449
|
|
|
|
|
Image procedure
prsb03-dataelement-12450
|
|
|
|
|
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 |
|
|
|
Performing professional
prsb03-dataelement-12452
|
|
|
| Id |
prsb03-dataelement-12452 (2019‑06‑19 15:54:56)
|
| Description |
The professional who performed the image procedure. |
| Relationship |
|
|
|
Name
prsb03-dataelement-12453
|
|
|
| Id |
prsb03-dataelement-12453 (2019‑06‑19 15:55:27)
|
| Concept inherits from |
prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
|
|
Role
prsb03-dataelement-12454
|
|
|
| Id |
prsb03-dataelement-12454 (2019‑06‑19 15:55:27)
|
| Concept inherits from |
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 |
|
|
|
Grade
prsb03-dataelement-12455
|
|
|
| Id |
prsb03-dataelement-12455 (2019‑06‑19 15:55:27)
|
| Concept inherits from |
prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Speciality
prsb03-dataelement-12456
|
|
|
|
|
Professional identifier
prsb03-dataelement-12457
|
|
|
| Id |
prsb03-dataelement-12457 (2019‑06‑19 15:55:27)
|
| Concept inherits from |
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 |
|
|
|
Organisation
prsb03-dataelement-12458
|
|
|
|
|
Contact details
prsb03-dataelement-12459
|
|
|
| Id |
prsb03-dataelement-12459 (2019‑06‑19 15:55:27)
|
| Concept inherits from |
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 |
|
|
|
Images
prsb03-dataelement-11158
|
|
|
|
|
Performing professional
prsb03-dataelement-12439
|
|
|
|
|
Name
prsb03-dataelement-12440
|
|
|
| Id |
prsb03-dataelement-12440 (2019‑06‑13 16:21:54)
|
| Concept inherits from |
prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
|
|
Role
prsb03-dataelement-12441
|
|
|
| Id |
prsb03-dataelement-12441 (2019‑06‑13 16:21:54)
|
| Concept inherits from |
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 |
|
|
|
Grade
prsb03-dataelement-12442
|
|
|
| Id |
prsb03-dataelement-12442 (2019‑06‑13 16:21:54)
|
| Concept inherits from |
prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
|
|
Speciality
prsb03-dataelement-12443
|
|
|
|
|
Professional identifier
prsb03-dataelement-12444
|
|
|
| Id |
prsb03-dataelement-12444 (2019‑06‑13 16:21:54)
|
| Concept inherits from |
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 |
|
|
|
Organisation
prsb03-dataelement-12445
|
|
|
|
|
Contact details
prsb03-dataelement-12446
|
|
|
| Id |
prsb03-dataelement-12446 (2019‑06‑13 16:21:54)
|
| Concept inherits from |
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
mimeType
prsb03-dataelement-11162
|
|
|
| Id |
prsb03-dataelement-11162 (2019‑05‑28 11:26:27)
|
| Description |
The type of image. |
| Operationalization |
Free text |
| Value Domain |
|
|
|
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 |
|
|
|
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 |
|
|
|
Unique id
prsb03-dataelement-11166
|
|
|
| Id |
prsb03-dataelement-11166 (2019‑05‑28 16:53:10)
|
| Description |
Image generated id. |
| Operationalization |
Free text. |
| Value Domain |
|
|
|
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 |
|
|
|
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 |
|
|
|
Person completing record
prsb03-dataelement-12462
|
|
|
|
|
Name
prsb03-dataelement-12463
|
|
|
| Id |
prsb03-dataelement-12463 (2019‑06‑19 16:09:03)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-12464
|
|
|
| Id |
prsb03-dataelement-12464 (2019‑06‑19 16:09:03)
|
| Concept inherits from |
prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
|
|
Grade
prsb03-dataelement-12465
|
|
|
| Id |
prsb03-dataelement-12465 (2019‑06‑19 16:09:03)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-12466
|
|
|
|
|
Organisation
prsb03-dataelement-12467
|
|
|
|
|
Professional identifier
prsb03-dataelement-12468
|
|
|
| Id |
prsb03-dataelement-12468 (2019‑06‑19 16:09:03)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-12469
|
|
|
| Id |
prsb03-dataelement-12469 (2019‑06‑19 16:09:03)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-12470
|
|
|
| Id |
prsb03-dataelement-12470 (2019‑06‑19 16:09:03)
|
| Concept inherits from |
prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Document status
prsb03-dataelement-10939
|
|
|
|
|
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.
|
|
|
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 |
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Name
prsb03-dataelement-13101
|
|
|
| Id |
prsb03-dataelement-13101 (2020‑06‑24 16:00:08)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
This concept is inherited by concept
Name in dataset prsb03-dataelement-13192
This concept is inherited by concept
Name in dataset prsb03-dataelement-13732
|
|
|
Role
prsb03-dataelement-13102
|
|
|
| Id |
prsb03-dataelement-13102 (2020‑06‑24 16:00:08)
|
| Concept inherits from |
prsb03-dataelement-13037 (2020‑04‑28 19:33:40)
|
| Description |
The organisational role of the person completing record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Relationship |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSjobrole
|
| Value Domain |
|
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
This concept is inherited by concept
Role in dataset prsb03-dataelement-13193
This concept is inherited by concept
Role in dataset prsb03-dataelement-13733
|
|
|
Grade
prsb03-dataelement-13103
|
|
|
| Id |
prsb03-dataelement-13103 (2020‑06‑24 16:00:08)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
This concept is inherited by concept
Grade in dataset prsb03-dataelement-13194
This concept is inherited by concept
Grade in dataset prsb03-dataelement-13734
|
|
|
Specialty
prsb03-dataelement-13104
|
|
|
| Id |
prsb03-dataelement-13104 (2020‑06‑24 16:00:08)
|
| Concept inherits from |
prsb03-dataelement-13039 (2020‑04‑28 19:33:40)
|
| Description |
The main specialty of the person completing the record. |
| FHIR |
PractitionerRole.specialty |
|
| Relationship |
|
| Rationale |
PractitionerRole.speciality |
| Operationalization |
NHS data dictionary :-
Activity treatment function code
|
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-13195
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-13735
|
|
|
Organisation
prsb03-dataelement-13105
|
|
|
| Id |
prsb03-dataelement-13105 (2020‑06‑24 16:00:08)
|
| Concept inherits from |
prsb03-dataelement-13040 (2020‑04‑28 19:33:40)
|
| Description |
The organisation the person completing the record works for. |
| Relationship |
|
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-13196
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-13736
|
|
|
Professional identifier
prsb03-dataelement-13106
|
|
|
| Id |
prsb03-dataelement-13106 (2020‑06‑24 16:00:08)
|
| Concept inherits from |
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.
|
| 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 |
|
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
|
|
|
Date completed
prsb03-dataelement-13107
|
|
|
| Id |
prsb03-dataelement-13107 (2020‑06‑24 16:00:08)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-13198
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-13738
|
|
|
Contact details
prsb03-dataelement-13108
|
|
|
| Id |
prsb03-dataelement-13108 (2020‑06‑24 16:00:08)
|
| Concept inherits from |
prsb03-dataelement-13043 (2020‑04‑28 19:33:40)
|
| Description |
Contact details of the person completing the record.
|
| FHIR |
PractitionerRole.telecom |
|
| Relationship |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telcom
|
| Operationalization |
NHS data dictionary : -
UK telephone number
|
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-13199
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-13739
|
|
|
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
|
|
|
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 |
|
|
|
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 |
|
|
|
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.
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
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 |
|
|
|
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 |
|
|
|
Discharge notice
prsb03-dataelement-13402
|
|
|
|
|
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 |
|
|
|
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 |
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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.
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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.
|
|
|
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.
|
|
|
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.
|
|
|
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.
|
|
|
Examination finding
prsb03-dataelement-14097
|
|
|
|
|
Examination type
prsb03-dataelement-14098
|
|
|
|
|
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.
|
|
|
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 |
|
|
|
Free text
prsb03-dataelement-14069
|
|
|
| Id |
prsb03-dataelement-14069 (2021‑02‑17 23:09:18)
|
| Concept inherits from |
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 |
|
|
|
Diagnosis
prsb03-dataelement-14070
|
|
|
|
|
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 |
|
|
|
Free text
prsb03-dataelement-14072
|
|
|
| Id |
prsb03-dataelement-14072 (2021‑02‑17 23:28:03) 0.1
|
| Concept inherits from |
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 |
|
|
|
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
|
|
|
Specialty
prsb03-dataelement-14015
|
|
|
|
|
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. |
|
|
| Relationship |
|
| Operationalization |
Date and time. |
| Value Domain |
|
| Property |
| Timestamp precision |
| at least day, month and year, hour and minute |
|
|
|
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 |
|
|
|
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 |
|
|
|
Coded value
prsb03-dataelement-13962
|
|
|
|
|
Free text
prsb03-dataelement-13963
|
|
|
|
|
Consultation method
prsb03-dataelement-14014
|
|
|
|
|
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).
|
| 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."
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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."
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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."
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Person completing record
prsb03-dataelement-14078
|
|
|
|
|
Name
prsb03-dataelement-14079
|
|
|
| Id |
prsb03-dataelement-14079 (2021‑02‑18 00:46:15)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-14080
|
|
|
| Id |
prsb03-dataelement-14080 (2021‑02‑18 00:46:15)
|
| Concept inherits from |
prsb03-dataelement-13909 (2021‑02‑02 22:37:50)
|
| Description |
The organisational role of the person completing the record. |
| 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 |
|
|
|
Grade
prsb03-dataelement-14081
|
|
|
| Id |
prsb03-dataelement-14081 (2021‑02‑18 00:46:15)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-14082
|
|
|
|
|
Organisation
prsb03-dataelement-14083
|
|
|
|
|
Coded value
prsb03-dataelement-14084
|
|
|
|
|
Free text
prsb03-dataelement-14085
|
|
|
| Id |
prsb03-dataelement-14085 (2021‑02‑18 00:46:15)
|
| Concept inherits from |
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 |
|
|
|
Professional identifier
prsb03-dataelement-14086
|
|
|
| Id |
prsb03-dataelement-14086 (2021‑02‑18 00:46:15)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-14087
|
|
|
| Id |
prsb03-dataelement-14087 (2021‑02‑18 00:46:15)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-14088
|
|
|
| Id |
prsb03-dataelement-14088 (2021‑02‑18 00:46:15)
|
| Concept inherits from |
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.).
|
| FHIR |
PractitionerRole.telecom |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telecom
|
| Operationalization |
NHS data dictionary :-
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
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."
|
|
|
In-between appointment interventions
prsb03-dataelement-14075
|
|
|
|
|
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. |
|
|
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. |
|
|
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.
|
|
|
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."
|
|
|
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 |
|
|
|
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 |
|
|
|
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)."
|
|
|
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)."
|
|
|
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 |
|
|
|
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 |
|
|
|
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)."
|
|
|
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 |
|
|
|
Free text
prsb03-dataelement-14107
|
|
|
| Id |
prsb03-dataelement-14107 (2021‑02‑22 13:16:02)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Free text in dataset prsb03-dataelement-14193
|
|
|
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).
|
|
|
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 |
|
|
|
Free text
prsb03-dataelement-14112
|
|
|
| Id |
prsb03-dataelement-14112 (2021‑02‑22 13:16:02)
|
| Concept inherits from |
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 |
|
|
|
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."
|
|
|
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 |
|
|
|
Free text
prsb03-dataelement-14110
|
|
|
| Id |
prsb03-dataelement-14110 (2021‑02‑22 13:16:02)
|
| Concept inherits from |
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 |
|
|
|
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. |
|
|
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."
|
|
|
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 |
|
|
|
Free text
prsb03-dataelement-14193
|
|
|
| Id |
prsb03-dataelement-14193 (2021‑02‑24 15:12:01)
|
| Concept inherits from |
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 |
|
|
|
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.
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 |
|
|
|
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.
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 |
|
|
|
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 |
|
|
|
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. |
|
|
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 |
|
|
|
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. |
|
|
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 |
|
|
|
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 |
|
|
|
Motivational interviewing placeholder
prsb03-dataelement-14233
|
|
|
|
|
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 |
|
|
|
Organisation
prsb03-dataelement-14116
|
|
|
|
|
Name
prsb03-dataelement-14117
|
|
|
| Id |
prsb03-dataelement-14117 (2021‑02‑22 13:16:02)
|
| Concept inherits from |
prsb03-dataelement-13935 (2021‑02‑03 11:20:19)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
|
|
Role
prsb03-dataelement-14118
|
|
|
| Id |
prsb03-dataelement-14118 (2021‑02‑22 13:16:02)
|
| Concept inherits from |
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 |
|
|
|
Grade
prsb03-dataelement-14119
|
|
|
| Id |
prsb03-dataelement-14119 (2021‑02‑22 13:16:02)
|
| Concept inherits from |
prsb03-dataelement-13937 (2021‑02‑03 11:20:19)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
|
|
Specialty
prsb03-dataelement-14120
|
|
|
|
|
Professional identifier
prsb03-dataelement-14121
|
|
|
| Id |
prsb03-dataelement-14121 (2021‑02‑22 13:16:02)
|
| Concept inherits from |
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 |
|
|
|
Organisation
prsb03-dataelement-14122
|
|
|
|
|
Coded value
prsb03-dataelement-14123
|
|
|
|
|
Free text
prsb03-dataelement-14124
|
|
|
| Id |
prsb03-dataelement-14124 (2021‑02‑22 13:16:02)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-14125
|
|
|
|
|
Person completing record
prsb03-dataelement-14126
|
|
|
|
|
Name
prsb03-dataelement-14127
|
|
|
| Id |
prsb03-dataelement-14127 (2021‑02‑22 13:16:02)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-14128
|
|
|
| Id |
prsb03-dataelement-14128 (2021‑02‑22 13:16:02)
|
| Concept inherits from |
prsb03-dataelement-13946 (2021‑02‑03 11:49:43)
|
| Description |
The organisational role of the person completing the record. |
| 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 |
|
|
|
Grade
prsb03-dataelement-14129
|
|
|
| Id |
prsb03-dataelement-14129 (2021‑02‑22 13:16:02)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-14130
|
|
|
|
|
Organisation
prsb03-dataelement-14131
|
|
|
|
|
Coded value
prsb03-dataelement-14132
|
|
|
|
|
Free text
prsb03-dataelement-14133
|
|
|
| Id |
prsb03-dataelement-14133 (2021‑02‑22 13:16:02)
|
| Concept inherits from |
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 |
|
|
|
Professional identifier
prsb03-dataelement-14134
|
|
|
| Id |
prsb03-dataelement-14134 (2021‑02‑22 13:16:02)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-14135
|
|
|
| Id |
prsb03-dataelement-14135 (2021‑02‑22 13:16:02)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-14136
|
|
|
| Id |
prsb03-dataelement-14136 (2021‑02‑22 13:16:02)
|
| Concept inherits from |
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.).
|
| FHIR |
PractitionerRole.telecom |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telecom
|
| Operationalization |
NHS data dictionary :-
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
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 |
|
|
|
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)."
|
|
|
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."
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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.
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Organisation
prsb03-dataelement-14045
|
|
|
|
|
Name
prsb03-dataelement-14046
|
|
|
| Id |
prsb03-dataelement-14046 (2021‑02‑15 17:40:29)
|
| Concept inherits from |
prsb03-dataelement-13897 (2021‑02‑01 20:13:26)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
|
|
Role
prsb03-dataelement-14047
|
|
|
| Id |
prsb03-dataelement-14047 (2021‑02‑15 17:40:29)
|
| Concept inherits from |
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 |
|
|
|
Grade
prsb03-dataelement-14048
|
|
|
| Id |
prsb03-dataelement-14048 (2021‑02‑15 17:40:29)
|
| Concept inherits from |
prsb03-dataelement-13899 (2021‑02‑01 20:23:02)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
|
|
Specialty
prsb03-dataelement-14049
|
|
|
|
|
Professional identifier
prsb03-dataelement-14050
|
|
|
| Id |
prsb03-dataelement-14050 (2021‑02‑15 17:40:29)
|
| Concept inherits from |
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 |
|
|
|
Organisation
prsb03-dataelement-14051
|
|
|
|
|
Coded value
prsb03-dataelement-14052
|
|
|
|
|
Free text
prsb03-dataelement-14053
|
|
|
| Id |
prsb03-dataelement-14053 (2021‑02‑15 17:40:29)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-14054
|
|
|
|
|
Person completing record
prsb03-dataelement-14055
|
|
|
|
|
Name
prsb03-dataelement-14056
|
|
|
| Id |
prsb03-dataelement-14056 (2021‑02‑17 11:36:42)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-14057
|
|
|
| Id |
prsb03-dataelement-14057 (2021‑02‑17 11:36:42)
|
| Concept inherits from |
prsb03-dataelement-13909 (2021‑02‑02 22:37:50)
|
| Description |
The organisational role of the person completing the record. |
| 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 |
|
|
|
Grade
prsb03-dataelement-14058
|
|
|
| Id |
prsb03-dataelement-14058 (2021‑02‑17 11:36:42)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-14059
|
|
|
|
|
Organisation
prsb03-dataelement-14060
|
|
|
|
|
Coded value
prsb03-dataelement-14061
|
|
|
|
|
Free text
prsb03-dataelement-14062
|
|
|
| Id |
prsb03-dataelement-14062 (2021‑02‑17 11:36:42)
|
| Concept inherits from |
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 |
|
|
|
Professional identifier
prsb03-dataelement-14063
|
|
|
| Id |
prsb03-dataelement-14063 (2021‑02‑17 11:36:42)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-14064
|
|
|
| Id |
prsb03-dataelement-14064 (2021‑02‑17 11:36:42)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-14065
|
|
|
| Id |
prsb03-dataelement-14065 (2021‑02‑17 11:36:42)
|
| Concept inherits from |
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.).
|
| FHIR |
PractitionerRole.telecom |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telecom
|
| Operationalization |
NHS data dictionary :-
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
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).
|
|
|
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).
|
|
|
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 |
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 12 times |
| |
This concept is inherited by concept
Free text in dataset prsb03-dataelement-14069
This concept is inherited by concept
Free text in dataset prsb03-dataelement-14072
This concept is inherited by concept
Free text in dataset prsb03-dataelement-13888
This concept is inherited by concept
Free text in dataset prsb03-dataelement-13890
This concept is inherited by concept
Free text in dataset prsb03-dataelement-13893
This concept is inherited by concept
Free text in dataset prsb03-dataelement-13905
This concept is inherited by concept
Free text in dataset prsb03-dataelement-13914
This concept is inherited by concept
Free text in dataset prsb03-dataelement-13925
This concept is inherited by concept
Free text in dataset prsb03-dataelement-13928
This concept is inherited by concept
Free text in dataset prsb03-dataelement-13931
This concept is inherited by concept
Free text in dataset prsb03-dataelement-14199
This concept is inherited by concept
Free text in dataset prsb03-dataelement-14202
|
|
|
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).
|
|
|
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 |
|
|
|
|
|
Free text
prsb03-dataelement-13888
|
|
|
| Id |
prsb03-dataelement-13888 (2021‑02‑01 18:50:44)
|
| Concept inherits from |
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 |
|
|
|
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).
|
|
|
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 |
|
|
|
Free text
prsb03-dataelement-13890
|
|
|
| Id |
prsb03-dataelement-13890 (2021‑02‑01 18:59:37)
|
| Concept inherits from |
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 |
|
|
|
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 |
|
|
|
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.
|
|
|
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).
|
|
|
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 |
|
|
|
Free text
prsb03-dataelement-13893
|
|
|
| Id |
prsb03-dataelement-13893 (2021‑02‑01 19:21:14)
|
| Concept inherits from |
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-14045
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-13934
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
This concept is inherited by concept
Name in dataset prsb03-dataelement-14046
This concept is inherited by concept
Name in dataset prsb03-dataelement-13935
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
This concept is inherited by concept
Role in dataset prsb03-dataelement-14047
This concept is inherited by concept
Role in dataset prsb03-dataelement-13936
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
This concept is inherited by concept
Grade in dataset prsb03-dataelement-14048
This concept is inherited by concept
Grade in dataset prsb03-dataelement-13937
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-14049
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-13938
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
|
|
|
Organisation
prsb03-dataelement-13903
|
|
|
| Id |
prsb03-dataelement-13903 (2021‑02‑02 21:35:36)
|
| Description |
The name of the organisation the professional works for. |
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-14051
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-13940
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
This concept is inherited by concept
Coded value in dataset prsb03-dataelement-14052
This concept is inherited by concept
Coded value in dataset prsb03-dataelement-13941
|
|
|
Free text
prsb03-dataelement-13905
|
|
|
| Id |
prsb03-dataelement-13905 (2021‑02‑02 21:45:00)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
This concept is inherited by concept
Free text in dataset prsb03-dataelement-14053
This concept is inherited by concept
Free text in dataset prsb03-dataelement-13942
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-14054
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-13943
|
|
|
Person completing record
prsb03-dataelement-13907
|
|
|
| Id |
prsb03-dataelement-13907 (2021‑02‑02 22:27:51)
|
| Description |
Details of the person completing the record. |
Used by
|
0 transactions, 0 templates, inherited 4 times |
| |
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 4 times |
| |
This concept is inherited by concept
Name in dataset prsb03-dataelement-14079
This concept is inherited by concept
Name in dataset prsb03-dataelement-14056
This concept is inherited by concept
Name in dataset prsb03-dataelement-13945
This concept is inherited by concept
Name in dataset prsb03-dataelement-14218
|
|
|
Role
prsb03-dataelement-13909
|
|
|
| Id |
prsb03-dataelement-13909 (2021‑02‑02 22:37:50)
|
| Description |
The organisational role of the person completing the record. |
| 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 |
|
Used by
|
0 transactions, 0 templates, inherited 4 times |
| |
This concept is inherited by concept
Role in dataset prsb03-dataelement-14080
This concept is inherited by concept
Role in dataset prsb03-dataelement-14057
This concept is inherited by concept
Role in dataset prsb03-dataelement-13946
This concept is inherited by concept
Role in dataset prsb03-dataelement-14219
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 4 times |
| |
This concept is inherited by concept
Grade in dataset prsb03-dataelement-14081
This concept is inherited by concept
Grade in dataset prsb03-dataelement-14058
This concept is inherited by concept
Grade in dataset prsb03-dataelement-13947
This concept is inherited by concept
Grade in dataset prsb03-dataelement-14220
|
|
|
Specialty
prsb03-dataelement-13911
|
|
|
| Id |
prsb03-dataelement-13911 (2021‑02‑02 22:47:46)
|
| Description |
The main specialty of the person completing the record. |
| FHIR |
PractitionerRole.specialty |
|
| Rationale |
PractitionerRole.specialty |
| Operationalization |
NHS data dictionary :-
Activity treatment function code
|
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited 4 times |
| |
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-14082
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-14059
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-13948
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-14221
|
|
|
Organisation
prsb03-dataelement-13912
|
|
|
| Id |
prsb03-dataelement-13912 (2021‑02‑02 22:55:15)
|
| Description |
The organisation the person completing the record works for. |
Used by
|
0 transactions, 0 templates, inherited 4 times |
| |
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-14083
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-14060
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-13949
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-14222
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 4 times |
| |
This concept is inherited by concept
Coded value in dataset prsb03-dataelement-14084
This concept is inherited by concept
Coded value in dataset prsb03-dataelement-14061
This concept is inherited by concept
Coded value in dataset prsb03-dataelement-13950
This concept is inherited by concept
Coded value in dataset prsb03-dataelement-14223
|
|
|
Free text
prsb03-dataelement-13914
|
|
|
| Id |
prsb03-dataelement-13914 (2021‑02‑02 23:02:16)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited 4 times |
| |
This concept is inherited by concept
Free text in dataset prsb03-dataelement-14085
This concept is inherited by concept
Free text in dataset prsb03-dataelement-14062
This concept is inherited by concept
Free text in dataset prsb03-dataelement-13951
This concept is inherited by concept
Free text in dataset prsb03-dataelement-14224
|
|
|
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.
|
| 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 |
|
Used by
|
0 transactions, 0 templates, inherited 4 times |
| |
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited 4 times |
| |
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-14087
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-14064
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-13953
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-14226
|
|
|
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.).
|
| FHIR |
PractitionerRole.telecom |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telecom
|
| Operationalization |
NHS data dictionary :-
UK telephone number
|
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited 4 times |
| |
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-14088
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-14065
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-13954
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-14227
|
|
|
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.
|
|
|
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)."
|
|
|
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 |
|
|
|
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 |
|
|
|
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)."
|
|
|
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)."
|
|
|
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 |
|
|
|
Free text
prsb03-dataelement-13925
|
|
|
| Id |
prsb03-dataelement-13925 (2021‑02‑03 10:18:29)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Free text in dataset prsb03-dataelement-14107
|
|
|
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."
|
|
|
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 |
|
|
|
Free text
prsb03-dataelement-13928
|
|
|
| Id |
prsb03-dataelement-13928 (2021‑02‑03 10:35:02)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Free text in dataset prsb03-dataelement-14110
|
|
|
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).
|
|
|
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 |
|
|
|
Free text
prsb03-dataelement-13931
|
|
|
| Id |
prsb03-dataelement-13931 (2021‑02‑03 10:46:20)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Free text in dataset prsb03-dataelement-14112
|
|
|
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 |
|
|
|
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 |
|
|
|
Organisation
prsb03-dataelement-13934
|
|
|
| Id |
prsb03-dataelement-13934 (2021‑02‑03 11:20:19)
|
| Concept inherits from |
prsb03-dataelement-13902 (2021‑02‑02 18:16:27)
|
| Description |
The name of the organisation the professional works for. |
| Value Domain |
|
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-14116
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-14207
|
|
|
Name
prsb03-dataelement-13935
|
|
|
| Id |
prsb03-dataelement-13935 (2021‑02‑03 11:20:19)
|
| Concept inherits from |
prsb03-dataelement-13897 (2021‑02‑01 20:13:26)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
This concept is inherited by concept
Name in dataset prsb03-dataelement-14117
This concept is inherited by concept
Name in dataset prsb03-dataelement-14208
|
|
|
Role
prsb03-dataelement-13936
|
|
|
| Id |
prsb03-dataelement-13936 (2021‑02‑03 11:20:19)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
This concept is inherited by concept
Role in dataset prsb03-dataelement-14118
This concept is inherited by concept
Role in dataset prsb03-dataelement-14209
|
|
|
Grade
prsb03-dataelement-13937
|
|
|
| Id |
prsb03-dataelement-13937 (2021‑02‑03 11:20:19)
|
| Concept inherits from |
prsb03-dataelement-13899 (2021‑02‑01 20:23:02)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
This concept is inherited by concept
Grade in dataset prsb03-dataelement-14119
This concept is inherited by concept
Grade in dataset prsb03-dataelement-14210
|
|
|
Specialty
prsb03-dataelement-13938
|
|
|
| Id |
prsb03-dataelement-13938 (2021‑02‑03 11:20:19)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-14120
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-14211
|
|
|
Professional identifier
prsb03-dataelement-13939
|
|
|
| Id |
prsb03-dataelement-13939 (2021‑02‑03 11:20:19)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
|
|
|
Organisation
prsb03-dataelement-13940
|
|
|
| Id |
prsb03-dataelement-13940 (2021‑02‑03 11:20:19)
|
| Concept inherits from |
prsb03-dataelement-13903 (2021‑02‑02 21:35:36)
|
| Description |
The name of the organisation the professional works for. |
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-14122
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-14213
|
|
|
Coded value
prsb03-dataelement-13941
|
|
|
| Id |
prsb03-dataelement-13941 (2021‑02‑03 11:20:19)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
This concept is inherited by concept
Coded value in dataset prsb03-dataelement-14123
This concept is inherited by concept
Coded value in dataset prsb03-dataelement-14214
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|
|
Free text
prsb03-dataelement-13942
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|
| Id |
prsb03-dataelement-13942 (2021‑02‑03 11:20:19)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
This concept is inherited by concept
Free text in dataset prsb03-dataelement-14124
This concept is inherited by concept
Free text in dataset prsb03-dataelement-14215
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Contact details
prsb03-dataelement-13943
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|
| Id |
prsb03-dataelement-13943 (2021‑02‑03 11:20:19)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited 2 times |
| |
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-14125
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-14216
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Person completing record
prsb03-dataelement-13944
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Name
prsb03-dataelement-13945
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|
|
| Id |
prsb03-dataelement-13945 (2021‑02‑03 11:49:43)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Name in dataset prsb03-dataelement-14127
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Role
prsb03-dataelement-13946
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|
| Id |
prsb03-dataelement-13946 (2021‑02‑03 11:49:43)
|
| Concept inherits from |
prsb03-dataelement-13909 (2021‑02‑02 22:37:50)
|
| Description |
The organisational role of the person completing the record. |
| 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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Role in dataset prsb03-dataelement-14128
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Grade
prsb03-dataelement-13947
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|
|
| Id |
prsb03-dataelement-13947 (2021‑02‑03 11:49:43)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Grade in dataset prsb03-dataelement-14129
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Specialty
prsb03-dataelement-13948
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|
|
| Id |
prsb03-dataelement-13948 (2021‑02‑03 11:49:43)
|
| Concept inherits from |
prsb03-dataelement-13911 (2021‑02‑02 22:47:46)
|
| Description |
The main specialty of the person completing the record. |
| FHIR |
PractitionerRole.specialty |
|
| Rationale |
PractitionerRole.specialty |
| Operationalization |
NHS data dictionary :-
Activity treatment function code
|
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-14130
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Organisation
prsb03-dataelement-13949
|
|
|
| Id |
prsb03-dataelement-13949 (2021‑02‑03 11:49:43)
|
| Concept inherits from |
prsb03-dataelement-13912 (2021‑02‑02 22:55:15)
|
| Description |
The organisation the person completing the record works for. |
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-14131
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|
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Coded value
prsb03-dataelement-13950
|
|
|
| Id |
prsb03-dataelement-13950 (2021‑02‑03 11:49:43)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Coded value in dataset prsb03-dataelement-14132
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|
|
Free text
prsb03-dataelement-13951
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|
|
| Id |
prsb03-dataelement-13951 (2021‑02‑03 11:49:43)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Free text in dataset prsb03-dataelement-14133
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|
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Professional identifier
prsb03-dataelement-13952
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|
|
| Id |
prsb03-dataelement-13952 (2021‑02‑03 11:49:43)
|
| Concept inherits from |
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.
|
| 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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
Date completed
prsb03-dataelement-13953
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|
|
| Id |
prsb03-dataelement-13953 (2021‑02‑03 11:49:43)
|
| Concept inherits from |
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-14135
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|
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Contact details
prsb03-dataelement-13954
|
|
|
| Id |
prsb03-dataelement-13954 (2021‑02‑03 11:49:43)
|
| Concept inherits from |
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.).
|
| FHIR |
PractitionerRole.telecom |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telecom
|
| Operationalization |
NHS data dictionary :-
UK telephone number
|
| Value Domain |
|
| Property |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-14136
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|
|
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. |
|
|
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.
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
Used by
|
0 transactions, 0 templates, inherited once |
| |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
CollaboRATE
prsb03-dataelement-14137
|
|
|
|
|
CollaboRATE for patients (5 point scale)
prsb03-dataelement-14149
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
CollaboRATE for patients (10 point scale)
prsb03-dataelement-14142
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
CollaboRATE for parents or guardians (10 point scale)
prsb03-dataelement-14138
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
CollaboRATE for individuals acting on behalf of patients (10 point scale)
prsb03-dataelement-14153
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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.
|
|
|
SDM-Q-9
prsb03-dataelement-14164
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
SDM-Q-Doc
prsb03-dataelement-14176
|
|
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
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. |
|
|
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
|
|
|
Performance measure name
prsb03-dataelement-14205
|
|
|
|
|
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 |
|
|
|
Location
prsb03-dataelement-14197
|
|
|
|
|
Coded value
prsb03-dataelement-14198
|
|
|
|
|
Free text
prsb03-dataelement-14199
|
|
|
| Id |
prsb03-dataelement-14199 (2021‑02‑25 23:26:22)
|
| Concept inherits from |
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 |
|
|
|
Consent form type
prsb03-dataelement-14200
|
|
|
|
|
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 |
|
|
|
Free text
prsb03-dataelement-14202
|
|
|
| Id |
prsb03-dataelement-14202 (2021‑02‑25 23:41:17)
|
| Concept inherits from |
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 |
|
|
|
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 |
|
|
|
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 |
|
|
|
Performing professional
prsb03-dataelement-14206
|
|
|
| Id |
prsb03-dataelement-14206 (2021‑02‑25 23:56:44)
|
| Description |
The professional who completed the consent form. |
| Relationship |
|
|
|
Organisation
prsb03-dataelement-14207
|
|
|
|
|
Name
prsb03-dataelement-14208
|
|
|
| Id |
prsb03-dataelement-14208 (2021‑02‑25 23:57:55)
|
| Concept inherits from |
prsb03-dataelement-13935 (2021‑02‑03 11:20:19)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
|
|
Role
prsb03-dataelement-14209
|
|
|
| Id |
prsb03-dataelement-14209 (2021‑02‑25 23:57:55)
|
| Concept inherits from |
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 |
|
|
|
Grade
prsb03-dataelement-14210
|
|
|
| Id |
prsb03-dataelement-14210 (2021‑02‑25 23:57:55)
|
| Concept inherits from |
prsb03-dataelement-13937 (2021‑02‑03 11:20:19)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
|
|
Specialty
prsb03-dataelement-14211
|
|
|
|
|
Professional identifier
prsb03-dataelement-14212
|
|
|
| Id |
prsb03-dataelement-14212 (2021‑02‑25 23:57:55)
|
| Concept inherits from |
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 |
|
|
|
Organisation
prsb03-dataelement-14213
|
|
|
|
|
Coded value
prsb03-dataelement-14214
|
|
|
|
|
Free text
prsb03-dataelement-14215
|
|
|
| Id |
prsb03-dataelement-14215 (2021‑02‑25 23:57:55)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-14216
|
|
|
|
|
Person completing record
prsb03-dataelement-14217
|
|
|
|
|
Name
prsb03-dataelement-14218
|
|
|
| Id |
prsb03-dataelement-14218 (2021‑02‑26 00:08:20)
|
| Concept inherits from |
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 |
|
|
|
Role
prsb03-dataelement-14219
|
|
|
| Id |
prsb03-dataelement-14219 (2021‑02‑26 00:08:20)
|
| Concept inherits from |
prsb03-dataelement-13909 (2021‑02‑02 22:37:50)
|
| Description |
The organisational role of the person completing the record. |
| 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 |
|
|
|
Grade
prsb03-dataelement-14220
|
|
|
| Id |
prsb03-dataelement-14220 (2021‑02‑26 00:08:20)
|
| Concept inherits from |
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 |
|
|
|
Specialty
prsb03-dataelement-14221
|
|
|
|
|
Organisation
prsb03-dataelement-14222
|
|
|
|
|
Coded value
prsb03-dataelement-14223
|
|
|
|
|
Free text
prsb03-dataelement-14224
|
|
|
| Id |
prsb03-dataelement-14224 (2021‑02‑26 00:08:20)
|
| Concept inherits from |
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 |
|
|
|
Professional identifier
prsb03-dataelement-14225
|
|
|
| Id |
prsb03-dataelement-14225 (2021‑02‑26 00:08:20)
|
| Concept inherits from |
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.
|
| 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 |
|
|
|
Date completed
prsb03-dataelement-14226
|
|
|
| Id |
prsb03-dataelement-14226 (2021‑02‑26 00:08:20)
|
| Concept inherits from |
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 |
|
|
|
Contact details
prsb03-dataelement-14227
|
|
|
| Id |
prsb03-dataelement-14227 (2021‑02‑26 00:08:20)
|
| Concept inherits from |
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.).
|
| FHIR |
PractitionerRole.telecom |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telecom
|
| Operationalization |
NHS data dictionary :-
UK telephone number
|
| Value Domain |
|
| Property |
|
|
|
Agenda Setting
prsb03-dataelement-14017
|
|
|
|
|
Generic item to be developed
prsb03-dataelement-13878
|
|
|
|
|
Test
prsb03-dataelement-12478
|
|
|
|
|
Attachments
prsb03-dataelement-10915
|
|
|
| Id |
prsb03-dataelement-10915 (2019‑04‑02 15:49:23)
|
| Concept inherits from |
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 |
|
|
|