Concept |
Card/Conf |
Id |
 |
Person demographics |
|
1 … 1 Mandatory |
prsb03-dataelement-10868 link
|
|
The person's details and contact information. |
 |
 |
Person name |
|
1 … 1 Mandatory |
prsb03-dataelement-10869 link
|
|
Details of the person's name |
|
1 … 1 Mandatory |
prsb03-dataelement-13799 link
|
|
The first name(s) of the person. This includes middle names.NHS data dictionary :- Person given name
|
|
1 … 1 Mandatory |
prsb03-dataelement-13800 link
|
|
The family name or surname of the personNHS data dictionary : - Person family name
|
|
0 … 1 |
prsb03-dataelement-10870 link
|
|
The name by which a person wishes to be addressed. The preferred name volunteered
by the person or a preferred name given by PDS that the person has asked to be called
by.NHS data dictionary: - Person full name
|
|
0 … 1 |
prsb03-dataelement-13089 link
|
|
Person's titleNHS data dictionary: - Person title
|
|
0 … 1 |
prsb03-dataelement-13798 link
|
|
A textual suffix that may be added to the end of a PERSON's name, for example, OBE,
MBE, BSc, JP, GMNHS data dictionary: - Person suffix
|
|
0 … 1 |
prsb03-dataelement-13801 link
|
|
The full name of the person in text representation.NHS data dictionary :- Patient full name
|
 |
|
Date of birth |
|
1 … 1 Mandatory |
prsb03-dataelement-10871 link
|
|
The date of birth of the person.NHS data dictionary:- Person birth date
|
 |
|
Gender |
|
0 … 1 |
prsb03-dataelement-10872 link
|
|
The person's stated gender.NHS data dictionary :- Person stated gender code
|
 |
|
Person alias |
|
0 … * |
prsb03-dataelement-10873 link
|
|
Other name(s) associated with the person.Free text |
 |
|
Ethnicity |
|
0 … 1 |
prsb03-dataelement-10874 link
|
|
The ethnicity of the person as specified by the person.NHS data dictionary :- Ethnic category
|
 |
|
Religion |
|
0 … 1 |
prsb03-dataelement-10876 link
|
|
The religious affiliation as specified by the person.
SNOMED_CT:- Religion
|
 |
|
Sex |
|
0 … 1 |
prsb03-dataelement-10877 link
|
|
The person’s phenotypic sex. Determines how the person will be treated clinically.NHS data dictionary: - person phenotypic sex
|
 |
|
NHS number |
|
0 … 1 |
prsb03-dataelement-10879 link
|
|
The unique identifier for a person within the NHS in England and Wales.NHS data dictionary:- NHS number
|
 |
|
Other identifier |
|
0 … * |
prsb03-dataelement-10880 link
|
|
Country specific or local identifier, e.g. Community Health Index (CHI) in Scotland.
NHS data dictionary: - Local patient identifier(extended), Health and care number
(NI only), Community health index number (Scotland only)
|
 |
 |
Person's address |
|
1 … * |
prsb03-dataelement-10881 link
|
|
Person’s usual place of residence, and where relevant temporary and correspondence
addresses.
|
|
1 … 1 Mandatory |
prsb03-dataelement-13082 link
|
|
Person's first line of address.
NHS data dictionary :- Address line 1
|
|
0 … 1 |
prsb03-dataelement-13083 link
|
|
Person's second line of address.
NHS data dictionary :- Address line 2
|
|
0 … 1 |
prsb03-dataelement-13084 link
|
|
Person's third line of address.
NHS data dictionary : - Address line 3
|
|
0 … 1 |
prsb03-dataelement-13085 link
|
|
Person's fourth line of address.
NHS data dictionary : - Address line 4
|
|
0 … 1 |
prsb03-dataelement-13086 link
|
|
Person's fifth line of address.NHS data dictionary : - Address line 5
|
|
1 … 1 Mandatory |
prsb03-dataelement-13087 link
|
|
The person's postcode.NHS data dictionary :- Postcode of usual address
|
|
0 … 1 |
prsb03-dataelement-13221 link
|
|
The type of address e.g. Main address, Temp addressNHS data dictionary : - Address association type
|
 |
 |
Person's contact details |
|
0 … 1 |
prsb03-dataelement-13804 link
|
|
Details of the person's contact information. |
|
0 … 1 |
prsb03-dataelement-10886 link
|
|
Preferred contact method, e.g. email, letter, phone, text message etc.NHS data dictionary :- Communication contact method
|
 |
 |
 |
Person's telephone number details |
|
0 … * |
prsb03-dataelement-10883 link
|
|
The person's telephone number details |
 |
 |
 |
|
Person's telephone number |
|
0 … 1 |
prsb03-dataelement-13808 link
|
|
The person's telephone numberNHS data dictionary : - UK telephone number
|
 |
 |
 |
|
Person's telephone number type |
|
0 … 1 |
prsb03-dataelement-13805 link
|
|
The contact type e.g. home, mobileFHIR value set: - Contact point use
|
 |
 |
 |
|
Preference of telephone number |
|
0 … 1 |
prsb03-dataelement-13809 link
|
|
The preferred order of use for the telephone numberPreference of use 1-5, 1 being the highest. |
 |
 |
 |
Person's email address details |
|
0 … * |
prsb03-dataelement-13807 link
|
|
Details of the person's email address |
|
0 … 1 |
prsb03-dataelement-10882 link
|
|
Email address of the person.NHS data dictionary :- Contact email address
|
 |
 |
 |
|
Person's email address type |
|
0 … 1 |
prsb03-dataelement-13811 link
|
|
The type of email address, home, workFHIR value set: - Contact point use
|
 |
 |
 |
|
Preference of email address |
|
0 … 1 |
prsb03-dataelement-13810 link
|
|
The preferred order of use of email addressPreference of use 1-5, 1 being the highest. |
 |
 |
|
Other contact information |
|
0 … * |
prsb03-dataelement-13806 link
|
|
Contact details via fax, sms, urlNHS data dictionary:- Communication contact string
|
 |
|
Place of birth |
|
0 … 1 |
prsb03-dataelement-10884 link
|
|
The country of birth of the person.NHS data dictionary :- Country code (birth)
|
 |
|
Marital status |
|
0 … 1 |
prsb03-dataelement-10885 link
|
|
An indicator to identify the legal marital status of the person.NHS data dictionary :- Person marital status
|
 |
GP practice |
|
1 … 1 Mandatory |
prsb03-dataelement-101 link
|
|
Details of the person's GP practice. |
 |
 |
GP practice record entry |
|
0 … * |
prsb03-dataelement-10643 link
|
|
This is an GP practice record entry. There may be 0 to many record entries under a
section. Each record entry is made up of a number of elements or data items
|
|
0 … 1 |
prsb03-dataelement-10003 link
|
|
The name of the person's GP. If the person is registered with a GP practice, their
usual GP name will be something volunteered by the person or their representative.Free text
|
|
0 … 1 |
prsb03-dataelement-10002 link
|
|
Name and address of the person's registered GP practice Registered GP practice details
are available from the Person Demographics Service (PDS), or volunteered from the
person or their representative. Include details of the practice name and address.Free text
|
|
1 … 1 Mandatory |
prsb03-dataelement-10001 link
|
|
The identifier of the registered GP practice.
NHS data dictionary : - General medical practice code (patient registration)
|
 |
About me |
|
0 … 1 |
prsb03-dataelement-466 link
|
|
About me |
 |
 |
What is most important to me |
|
0 … 1 |
prsb03-dataelement-12964 link
|
|
A description of what is most important to you.
|
 |
 |
|
What is most important to me |
|
0 … 1 |
prsb03-dataelement-14325 link
|
|
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, volunteeringFree text
|
 |
 |
People who are important to me |
|
0 … 1 |
prsb03-dataelement-13009 link
|
|
Details of who is important to you and why. |
 |
 |
|
People who are important to me |
|
0 … 1 |
prsb03-dataelement-14327 link
|
|
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 sayFree text
|
 |
 |
How I communicate and how to communicate with me |
|
0 … 1 |
prsb03-dataelement-13006 link
|
|
A description of how you communicate normally. |
 |
 |
|
How I communicate and how to communicate with me |
|
0 … 1 |
prsb03-dataelement-14329 link
|
|
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.
Free text
|
 |
 |
My wellness |
|
0 … 1 |
prsb03-dataelement-13005 link
|
|
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.
|
|
0 … 1 |
prsb03-dataelement-14331 link
|
|
Free text
|
 |
 |
Please do and please don't |
|
0 … 1 |
prsb03-dataelement-13008 link
|
|
A description of things you want someone supporting you to do (or not to do). |
 |
 |
|
Please do and please don't |
|
0 … 1 |
prsb03-dataelement-14333 link
|
|
A description of things you want someone supporting you to do (or not to do). Things you want someone to do might include (for example): - 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 you to do might include (for example): - 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, undergoing a specific intervention
or taking a medication the person does not want.Free text
|
 |
 |
How and when to support me |
|
0 … 1 |
prsb03-dataelement-13007 link
|
|
A description of how and when you want someone caring for you to support you. |
 |
 |
|
How and when to support me |
|
0 … 1 |
prsb03-dataelement-14335 link
|
|
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.
Free text
|
 |
 |
Also worth knowing about me |
|
0 … 1 |
prsb03-dataelement-13094 link
|
|
A description of what is also worth knowing about you for people caring or supporting
you.
|
 |
 |
|
Also worth knowing about me |
|
0 … 1 |
prsb03-dataelement-14337 link
|
|
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.
Free text
|
 |
|
Date |
|
0 … 1 |
prsb03-dataelement-10367 link
|
|
This is a record of the date that this information was last updated.Date and Time |
 |
|
Supported to write this by |
|
0 … 1 |
prsb03-dataelement-10368 link
|
|
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.Free text
|
 |
|
Location to multimedia file |
|
0 … 1 |
prsb03-dataelement-14326 link
|
|
The link to the person's multimedia fileLink to URL |
 |
Professional contacts |
|
0 … 1 |
prsb03-dataelement-452 link
|
|
The details of the person’s professional contacts. |
 |
 |
Professional contacts record entry |
|
0 … * |
prsb03-dataelement-10767 link
|
|
This is a professional contacts record entry. There may be 0 to many record entries
under a section. Each record entry is made up of a number of elements or data items.
|
|
0 … 1 |
prsb03-dataelement-10352 link
|
|
The name of the professional with responsibility for the care of the person.Free text |
|
0 … 1 |
prsb03-dataelement-10353 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker, key worker, care home manager, care coordinator, LA
hospital liaison person, care home contact, hospital clinician, Independent Mental
Capacity Advocate (IMCA) etcFHIR value set : - SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-12973 link
|
|
A flag that identifies the personal contact is the key worker assigned to the person.Flag : - Yes or No |
|
0 … 1 |
prsb03-dataelement-10354 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary : - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-10355 link
|
|
The name of the team.Free text |
|
0 … 1 |
prsb03-dataelement-10356 link
|
|
The name of the organisation. |
|
0 … 1 |
prsb03-dataelement-13564 link
|
|
The coded value for locationNHS data dictionary : - Organisation data service
|
|
0 … 1 |
prsb03-dataelement-13565 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-10357 link
|
|
Contact details of the professional (e.g. telephone number, email address etc.).Free text |
|
0 … 1 |
prsb03-dataelement-10358 link
|
|
The start date of the professional relationship with the person.Date and time |
|
0 … 1 |
prsb03-dataelement-10359 link
|
|
The end date of the professional relationship with the person.Date and time |
 |
Personal contacts |
|
0 … 1 |
prsb03-dataelement-445 link
|
|
The details of the individual's personal contacts. |
 |
 |
Personal contacts record entry |
|
0 … * |
prsb03-dataelement-10768 link
|
|
This is personal contacts record entry. There may be 0 to many record entries under
a section. Each record entry is made up of a number of elements or data items.
|
|
1 … 1 Mandatory |
prsb03-dataelement-10345 link
|
|
The name of the personal contact.Free text |
|
0 … 1 |
prsb03-dataelement-10346 link
|
|
The relationship the personal contact has to the person, e.g. father, grandmother,
family friend etc.FHIR value set : - Related person
|
|
0 … 1 |
prsb03-dataelement-12968 link
|
|
Additional roles the person performs on behalf of the other (e.g. Carer, Next of Kin,
Emergency Contact, Dependent, etc.)Free text
|
|
0 … 1 |
prsb03-dataelement-10350 link
|
|
Contact details of the personal contact (e.g. telephone number, email address etc.)Free Text |
|
0 … 1 |
prsb03-dataelement-10937 link
|
|
Notes on the significance of the personal contact to the person.Free text |
 |
Formulation |
|
0 … 1 |
prsb03-dataelement-11666 link
|
|
Details of the person's formulation. |
 |
 |
Formulation record entry |
|
0 … * |
prsb03-dataelement-11667 link
|
|
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.
|
|
0 … 1 |
prsb03-dataelement-11669 link
|
|
The date the formulation was made.Date and time. |
|
0 … 1 |
prsb03-dataelement-11670 link
|
|
The location where the formulation was made.NHS data dictionary: - Organisation data service
|
|
0 … 1 |
prsb03-dataelement-13572 link
|
|
The coded value for locationNHS data dictionary: - Organisation data service
|
|
0 … 1 |
prsb03-dataelement-13573 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-11671 link
|
|
The professional who made the formulation. |
|
0 … 1 |
prsb03-dataelement-11672 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-11673 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
0 … 1 |
prsb03-dataelement-11674 link
|
|
The grade of the professional.Free text |
|
0 … 1 |
prsb03-dataelement-11675 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-11676 link
|
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-11677 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-11678 link
|
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
0 … 1 |
prsb03-dataelement-11668 link
|
|
An account, shared by a therapist and person, of the personal meaning and origins
of a person’s difficulties. This is viewed in the context of multiple factors including
relationships, social circumstances and life events and will indicate the most helpful
way forward.Free text
|
|
0 … 1 |
prsb03-dataelement-11679 link
|
|
Details of the person completing the record. |
|
0 … 1 |
prsb03-dataelement-11680 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-11681 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-11682 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-11683 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-11684 link
|
|
The organisation the person completing the record works for. |
|
0 … 1 |
prsb03-dataelement-11685 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-11686 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-11687 link
|
|
Contact details of the person completing the record.
NHS data dictionary : - UK telephone number
|
 |
Care and support plan |
|
0 … 1 |
prsb03-dataelement-508 link
|
|
This records the decisions reached during conversation between the individual and
health and care professional about future plans and also records progress.
|
 |
 |
Strengths |
|
0 … * |
prsb03-dataelement-10419 link
|
|
Any strengths and assets the person has relating to their goals and hopes about their
health and well-being.
|
|
0 … 1 |
prsb03-dataelement-14369 link
|
|
The coded value associated with the person's strengths. Could be derived from the
assessment of the person e.g. 300738008 |Able to participate in leisure activities
(finding)|
SNOMED CT : - 1127601000000107 | Healthcare matters simple reference set (foundation
metadata concept) |
|
|
0 … 1 |
prsb03-dataelement-14370 link
|
|
Any supplementary or personalised information that relates to the person's strengths.Free text |
 |
 |
Needs, concerns or problems |
|
0 … * |
prsb03-dataelement-10414 link
|
|
Details of the person needs, concerns or problems
|
|
0 … 1 |
prsb03-dataelement-14371 link
|
|
The coded value associated with the person's needs, concerns or problems.SNOMED CT : - ^1127581000000103 |Health issues simple reference set|
|
|
0 … 1 |
prsb03-dataelement-14372 link
|
|
Any supplementary or personalised information that relates to the person's needs,
concerns and problems.
|
Free text
|
|
0 … * |
prsb03-dataelement-10413 link
|
|
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.
|
|
|
0 … 1 |
prsb03-dataelement-14373 link
|
|
The coded value associated with the person's goals, aim's and hopes. e.g. 999002111000000103
|Occupational therapy goals simple reference set (foundation metadata concept)|SNOMED CT : - 413350009|Finding with explicit context|: 246090004|Associated finding|=300798006
|Able to participate in sporting activities (finding)|, 408729009|Finding context|=410518001|Goal|
|
|
0 … 1 |
prsb03-dataelement-14374 link
|
|
Any supplementary and personalised information relating to the person's goals, aims
and hopes.Free text
|
|
0 … 1 |
prsb03-dataelement-14399 link
|
|
Assessment of the person's motivations to achieve this goal, how important the goal
is to the person on a scale of 1-10.Numeric scale 1 - 10
|
|
0 … * |
prsb03-dataelement-10408 link
|
|
Actions or activities the person or others plan to take to achieve the person's goals
and the resources required to do this.
|
|
0 … * |
prsb03-dataelement-10675 link
|
|
What the action is and how it is to be carried out? |
|
0 … 1 |
prsb03-dataelement-14383 link
|
|
The coded value for the action.
SNOMED CT : - <<71388002 |Procedure| OR <<129125009 |Procedure with explicit context|
|
|
0 … 1 |
prsb03-dataelement-14384 link
|
|
Any supplementary and personalised information for the action.Free text |
|
0 … 1 |
prsb03-dataelement-10676 link
|
|
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.
|
|
0 … 1 |
prsb03-dataelement-14393 link
|
|
The name of the professional or person carrying out the proposed action.Free text |
|
0 … 1 |
prsb03-dataelement-14394 link
|
|
The role of the person providing the service.FHIR values set : - sdsjobrole
|
|
0 … 1 |
prsb03-dataelement-14395 link
|
|
The name of the team.Free text |
|
0 … 1 |
prsb03-dataelement-14396 link
|
|
Contact details of the professional (e.g. telephone number, email address etc.).Free text |
|
0 … 1 |
prsb03-dataelement-10677 link
|
|
Planned date, time, or interval, as relevantDate and time |
|
0 … 1 |
prsb03-dataelement-10678 link
|
|
Suggested strategies for potential problems.Free text. |
|
0 … 1 |
prsb03-dataelement-10679 link
|
|
The status of the action or activity e.g. in progress, done, refused |
|
0 … 1 |
prsb03-dataelement-14385 link
|
|
The coded value for the person's activity statusSNOMED CT : - ^999000081000000105 | Care planning action context values simple reference
set (foundation metadata concept) |
|
|
0 … 1 |
prsb03-dataelement-14386 link
|
|
Any supplementary or personalised information for the person's activity statusFree text |
|
0 … 1 |
prsb03-dataelement-10680 link
|
|
How confident the person feels to carry out the action associated to the goal.Numeric score 1 - 10 |
|
0 … 1 |
prsb03-dataelement-10682 link
|
|
Date when action/activity record was last updatedDate and time |
|
0 … 1 |
prsb03-dataelement-10683 link
|
|
When the action evaluation needs to be reviewed. SNOMED CT tag : - 425268008 | Review
of care plan (procedure) |Date and time.
|
|
0 … * |
prsb03-dataelement-10674 link
|
|
Details of the person's stage goals |
|
0 … 1 |
prsb03-dataelement-14284 link
|
|
A specific sub-goal that is related to the overall goal as agreed by the person in
collaboration with a professional.
|
|
0 … 1 |
prsb03-dataelement-14375 link
|
|
The coded expression associated with the person's stage goal.SNOMED CT : - 413350009|Finding with explicit context|: 246090004|Associated finding|=300798006
|Able to participate in sporting activities (finding)|, 408729009|Finding context|=410518001|Goal|
|
|
0 … 1 |
prsb03-dataelement-14376 link
|
|
Any supplementary or personalised information regarding the person's stage goal.Free text |
|
0 … 1 |
prsb03-dataelement-10681 link
|
|
The outcome of the stage goal
|
|
0 … 1 |
prsb03-dataelement-14378 link
|
|
The coded value for the person's stage goal outcome.SNOMED CT: - ^1127601000000107 |Healthcare matters simple reference set (foundation
metadata concept)|
|
|
0 … 1 |
prsb03-dataelement-14379 link
|
|
Any supplementary and personalised information relating to the person's outcome.Free text |
|
0 … 1 |
prsb03-dataelement-14377 link
|
|
The status associated with the person's stage goalSNOMED CT: - ^999000091000000107 | Care planning goal context values simple reference
set (foundation metadata concept) |
|
|
0 … * |
prsb03-dataelement-10416 link
|
|
Outcomes of each of the person’s goals, aims and targets. Includes comments recorded
by the person, date and status.
|
|
0 … 1 |
prsb03-dataelement-14380 link
|
|
The coded value associated with the person's overall goal outcomeSNOMED CT: - ^1127601000000107 |Healthcare matters simple reference set (foundation
metadata concept)|
|
|
0 … 1 |
prsb03-dataelement-14382 link
|
|
Any supplementary and personalised information relating to the person's goal outcome.
Free text
|
|
0 … 1 |
prsb03-dataelement-14400 link
|
|
The status associated with the person's overall goal.SNOMED CT: - ^999000091000000107 | Care planning goal context values simple reference
set (foundation metadata concept) |
|
 |
 |
Agreed with person or legitimate representative |
|
0 … 1 |
prsb03-dataelement-10409 link
|
|
Indicates whether the plan was discussed and agreed with the person or legitimate
representative.
|
 |
 |
|
Person or legitimate representative |
|
0 … 1 |
prsb03-dataelement-14322 link
|
|
Indicates whether the plan was discussed and agreed with the person or legitimate
representativePerson or legitimate representative
|
|
0 … 1 |
prsb03-dataelement-14323 link
|
|
The full name of the person in text representation.NHS data dictionary :- Patient full name
|
|
0 … 1 |
prsb03-dataelement-14324 link
|
|
The role the professional has in relation to the person.FHIR value set : - sdsjobrole
|
 |
 |
Care funding source |
|
0 … 1 |
prsb03-dataelement-10410 link
|
|
A reference to the funding source and any conditions or limitations associated. |
|
0 … 1 |
prsb03-dataelement-14391 link
|
|
The organisation code of the care funding sourceNHS data dictionary : - organisation data service
|
|
0 … 1 |
prsb03-dataelement-14392 link
|
|
Any further information for the person's care funding source e.g. self fundedFree text |
 |
|
Date this plan was last updated |
|
0 … 1 |
prsb03-dataelement-10412 link
|
|
This is a record of the date that this care and support plan was last updated.Date and time |
 |
|
Other care planning documents |
|
0 … * |
prsb03-dataelement-10415 link
|
|
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.Free text.
|
 |
|
Planned review date/interval |
|
0 … 1 |
prsb03-dataelement-10417 link
|
|
This is the date/interval when this information will next be reviewed. SNOMED CT tag
: - 425268008 | Review of care plan (procedure) |Date and time
|
 |
 |
Responsibility for review |
|
0 … 1 |
prsb03-dataelement-10418 link
|
|
This is a record of who has responsibility for arranging review of this information.
|
|
0 … 1 |
prsb03-dataelement-14345 link
|
|
The name of the professional with responsibility for the care of the person.Free text |
|
0 … 1 |
prsb03-dataelement-14346 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker, key worker, care home manager, care coordinator, LA
hospital liaison person, care home contact, hospital clinician, Independent Mental
Capacity Advocate (IMCA) etcFHIR value set : - SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-14347 link
|
|
Contact details of the professional (e.g. telephone number, email address etc.).Free text |
 |
 |
Location |
|
0 … 1 |
prsb03-dataelement-12044 link
|
|
The location where the care and support plan was prepared. |
|
0 … 1 |
prsb03-dataelement-13665 link
|
|
The coded value for locationNHS data dictionary: - Organisation data service
|
|
0 … 1 |
prsb03-dataelement-13666 link
|
|
Free text field to be used if no coded text available |
 |
 |
Performing professional |
|
0 … 1 |
prsb03-dataelement-12027 link
|
|
The professional who prepared the care and support plan. |
|
0 … 1 |
prsb03-dataelement-12028 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-12029 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
0 … 1 |
prsb03-dataelement-12030 link
|
|
The grade of the professional.Free text |
|
0 … 1 |
prsb03-dataelement-12031 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-12032 link
|
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-12033 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-12034 link
|
|
Contact details of the professionalNHS data dictionary - UK phone number
|
 |
 |
Person completing record |
|
0 … * |
prsb03-dataelement-12035 link
|
|
Details of the person completing the record. |
|
0 … 1 |
prsb03-dataelement-12036 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-12037 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-12038 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-12039 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-12040 link
|
|
The organisation the person completing the record works for. |
|
0 … 1 |
prsb03-dataelement-12041 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-12042 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-12043 link
|
|
Contact details of the person completing the record.
NHS data dictionary : - UK telephone number
|
 |
Contingency/safety plans |
|
0 … * |
prsb03-dataelement-469 link
|
|
These are the things to do and people to contact, should an individual’s
health or other circumstances get worse for safety.
|
 |
 |
Trigger factors |
|
1 … * Mandatory |
prsb03-dataelement-10375 link
|
|
Signs to watch out for that may indicate a significant change in health or other circumstances
e.g. feeling agitated
|
|
0 … 1 |
prsb03-dataelement-14389 link
|
|
The trigger that leads to instigation of a significant change in health or other circumstances.
SNOMED CT: - ^1127581000000103 | Health issues simple reference set (foundation metadata
concept) |
|
|
0 … 1 |
prsb03-dataelement-14390 link
|
|
Any free text associated with the person's trigger factorFree text |
 |
 |
Contingency plan name |
|
0 … 1 |
prsb03-dataelement-10371 link
|
|
When the action evaluation needs to be reviewed. |
|
0 … 1 |
prsb03-dataelement-14387 link
|
|
The coded value for the type of care planSNOMED CT: - 999001471000000108 | Care plan type simple reference set (foundation
metadata concept) |
|
|
0 … 1 |
prsb03-dataelement-14388 link
|
|
Free text if no coded value is available.Free text |
 |
 |
What should happen |
|
0 … * |
prsb03-dataelement-10376 link
|
|
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.
|
|
0 … 1 |
prsb03-dataelement-14403 link
|
|
The coded value for what should happen
SNOMED CT : - <<71388002 |Procedure| OR <<129125009 |Procedure with explicit context|
|
|
0 … 1 |
prsb03-dataelement-14404 link
|
|
Any supplementary or personalised information regarding what should happen
Free text
|
 |
 |
Who should be contacted |
|
0 … * |
prsb03-dataelement-10377 link
|
|
Who should be contacted in the event of significant problems or deterioration in health
or wellbeing. e.g. name, role and contact details.
|
|
0 … 1 |
prsb03-dataelement-14405 link
|
|
The name of the professional with responsibility for the care of the person.Free text |
|
0 … 1 |
prsb03-dataelement-14406 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker, key worker, care home manager, care coordinator, LA
hospital liaison person, care home contact, hospital clinician, Independent Mental
Capacity Advocate (IMCA) etcFHIR value set : - SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-14407 link
|
|
Contact details of the personal contact (e.g. telephone number, email address etc.)Free Text |
 |
 |
Agreed with person or legitimate representative |
|
0 … 1 |
prsb03-dataelement-10369 link
|
|
Indicates whether the plan was discussed and agreed with the person or legitimate
representative.
|
 |
 |
|
Person or legitimate representative |
|
0 … 1 |
prsb03-dataelement-14339 link
|
|
Indicates whether the plan was discussed and agreed with the person or legitimate
representativePerson or legitimate representative
|
|
0 … 1 |
prsb03-dataelement-14340 link
|
|
The full name of the person in text representation.NHS data dictionary :- Patient full name
|
|
0 … 1 |
prsb03-dataelement-14341 link
|
|
The role the professional has in relation to the person.FHIR value set : - sdsjobrole
|
 |
|
Date this plan was last updated |
|
0 … 1 |
prsb03-dataelement-10372 link
|
|
The date that this contingency plan was last updated.Date and time |
 |
|
Planned review date/interval |
|
0 … 1 |
prsb03-dataelement-10373 link
|
|
This is the date/interval when this contingency plan will next be reviewed. SNOMED
CT tag : - 425268008 | Review of care plan (procedure) |Date and time
|
 |
 |
Responsibility for review |
|
0 … 1 |
prsb03-dataelement-10374 link
|
|
This is who has responsibility for arranging review of this information.
|
|
0 … 1 |
prsb03-dataelement-14342 link
|
|
The name of the professional with responsibility for the care of the person.Free text |
|
0 … 1 |
prsb03-dataelement-14343 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker, key worker, care home manager, care coordinator, LA
hospital liaison person, care home contact, hospital clinician, Independent Mental
Capacity Advocate (IMCA) etcFHIR value set : - SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-14344 link
|
|
Contact details of the professional (e.g. telephone number, email address etc.).Free text |
 |
 |
Coping strategies |
|
0 … * |
prsb03-dataelement-13850 link
|
|
Details of coping strategies used |
|
0 … 1 |
prsb03-dataelement-13851 link
|
|
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.Free text
|
|
0 … 1 |
prsb03-dataelement-13852 link
|
|
The date when the coping strategy startedDate and time |
|
0 … 1 |
prsb03-dataelement-13853 link
|
|
The date when the coping strategy endedDate and time |
 |
 |
Relapse indicators / early warning signs |
|
0 … * |
prsb03-dataelement-13854 link
|
|
Details of the relapse indicators for the person. These may also be called 'early
warning signs'
|
|
0 … 1 |
prsb03-dataelement-14401 link
|
|
The coded value for relapse indicators/early warning signsSNOMED CT : - ^1127601000000107 | Healthcare matters simple reference set (foundation
metadata concept) |
|
|
0 … 1 |
prsb03-dataelement-14402 link
|
|
Any supplementary or personalised information regarding the relapse indicators/early
warning signsFree text
|
 |
 |
Advance statement |
|
0 … 1 |
prsb03-dataelement-10777 link
|
|
Written requests and preferences made by a person with capacity conveying their wishes,
beliefs and values for their future care should they lose capacity.
|
|
0 … 1 |
prsb03-dataelement-12267 link
|
|
The date when the advanced statements was made.Date and time |
|
0 … 1 |
prsb03-dataelement-12268 link
|
|
The location where the advanced statement was made. |
|
0 … 1 |
prsb03-dataelement-13698 link
|
|
The coded value for locationNHS data dictionary: - Organisation data service
|
|
0 … 1 |
prsb03-dataelement-13699 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-13695 link
|
|
Does the person have an advance statement. |
|
0 … 1 |
prsb03-dataelement-13696 link
|
|
The coded value for advance statementSNOMED CT: - 816281000000101 | Has advance statement (Mental Capacity Act 2005) (finding)
|
|
|
0 … 1 |
prsb03-dataelement-13697 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-13760 link
|
|
The location of where the advanced statement is held.Free text or URL |
|
0 … 1 |
prsb03-dataelement-12269 link
|
|
The professional who made the advance statement. |
|
0 … 1 |
prsb03-dataelement-12270 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-12271 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
0 … 1 |
prsb03-dataelement-12272 link
|
|
The grade of the professional.Free text |
|
0 … 1 |
prsb03-dataelement-12273 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-12274 link
|
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-12275 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-12276 link
|
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
0 … 1 |
prsb03-dataelement-12277 link
|
|
Details of the person completing the record. |
|
0 … 1 |
prsb03-dataelement-12278 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-12279 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-12280 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-12281 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-12282 link
|
|
The organisation the person completing the record works for. |
|
0 … 1 |
prsb03-dataelement-12283 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-12284 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-12285 link
|
|
Contact details of the person completing the record.
NHS data dictionary : - UK telephone number
|
 |
|
Anticipatory medicines/equipment |
|
0 … * |
prsb03-dataelement-10370 link
|
|
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.
SNOMED CT Tag : - 871021000000106 | Prescription of palliative care anticipatory medication
(procedure) |Free text
|
 |
 |
Location |
|
0 … * |
prsb03-dataelement-12079 link
|
|
The location where the contingency plan was prepared. |
|
0 … 1 |
prsb03-dataelement-13667 link
|
|
The coded value for locationNHS data dictionary : - Organisation data service
|
|
0 … 1 |
prsb03-dataelement-13668 link
|
|
Free text field to be used if no code is availableFree text |
 |
 |
Performing professional |
|
0 … 1 |
prsb03-dataelement-12045 link
|
|
The professional who prepared the contingency plans. |
|
0 … 1 |
prsb03-dataelement-12046 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-12047 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
0 … 1 |
prsb03-dataelement-12048 link
|
|
The grade of the professional.Free text |
|
0 … 1 |
prsb03-dataelement-12049 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-12050 link
|
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-12051 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-12052 link
|
|
Contact details of the professionalNHS data dictionary - UK phone number
|
 |
 |
Person completing record |
|
0 … 1 |
prsb03-dataelement-12053 link
|
|
Details of the person completing the record. |
|
0 … 1 |
prsb03-dataelement-12054 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-12055 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-12056 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-12057 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-12058 link
|
|
The organisation the person completing the record works for. |
|
0 … 1 |
prsb03-dataelement-12059 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-12060 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-12061 link
|
|
Contact details of the person completing the record.
NHS data dictionary : - UK telephone number
|
 |
Additional support plans |
|
0 … * |
prsb03-dataelement-502 link
|
|
Additional support plans |
 |
 |
Additional support plan name |
|
0 … 1 |
prsb03-dataelement-10402 link
|
|
The name of the particular additional supporting plan, e.g. dieticians plan, wound
management plan, discharge management plan and behaviour support plan.
|
|
0 … 1 |
prsb03-dataelement-14397 link
|
|
The coded value for the type of care planSNOMED CT: - 999001471000000108 | Care plan type simple reference set (foundation
metadata concept) |
|
|
0 … 1 |
prsb03-dataelement-14398 link
|
|
Free text if no coded value is availableFree text |
 |
|
Additional support plan content |
|
0 … 1 |
prsb03-dataelement-10403 link
|
|
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.Free text
|
 |
|
Planned review date/interval |
|
0 … 1 |
prsb03-dataelement-10405 link
|
|
This is the date/interval when this information will next be reviewed. SNOMED CT tag
: - 425268008 | Review of care plan (procedure) |Date and time
|
 |
 |
Responsibility for review |
|
0 … 1 |
prsb03-dataelement-10406 link
|
|
This is a record of who has responsibility for arranging review of this information.
Should include their name, role and contact details.
|
|
0 … 1 |
prsb03-dataelement-14348 link
|
|
The name of the professional with responsibility for the care of the person.Free text |
|
0 … 1 |
prsb03-dataelement-14349 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker, key worker, care home manager, care coordinator, LA
hospital liaison person, care home contact, hospital clinician, Independent Mental
Capacity Advocate (IMCA) etcFHIR value set : - SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-14350 link
|
|
Contact details of the professional (e.g. telephone number, email address etc.).Free text |
 |
|
Date this plan was last updated |
|
0 … 1 |
prsb03-dataelement-10407 link
|
|
This is a record of the date that this information was last updated.Date and time |
 |
 |
Location |
|
0 … 1 |
prsb03-dataelement-12080 link
|
|
The location where the additional support plan was prepared.ODS code or free text |
|
0 … 1 |
prsb03-dataelement-13722 link
|
|
The coded value for locationNHS data dictionary:- Organisation data service
|
|
0 … 1 |
prsb03-dataelement-13723 link
|
|
Free text field to be used if no code is availableFree text |
 |
 |
Performing professional |
|
0 … 1 |
prsb03-dataelement-12062 link
|
|
The professional who prepared the additional support plan. |
|
0 … 1 |
prsb03-dataelement-12063 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-12064 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
0 … 1 |
prsb03-dataelement-12065 link
|
|
The grade of the professional.Free text |
|
0 … 1 |
prsb03-dataelement-12066 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-12067 link
|
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-12068 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-12069 link
|
|
Contact details of the professionalNHS data dictionary - UK phone number
|
 |
 |
Person completing record |
|
0 … 1 |
prsb03-dataelement-12070 link
|
|
Details of the person completing the record. |
|
0 … 1 |
prsb03-dataelement-12071 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-12072 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-12073 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-12074 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-12075 link
|
|
The organisation the person completing the record works for. |
|
0 … 1 |
prsb03-dataelement-12076 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-12077 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-12078 link
|
|
Contact details of the person completing the record.
NHS data dictionary : - UK telephone number
|