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draft Transaction Cardiovascular Disease (GP) 2.16.840.1.113883.3.1937.777.28.4.239

Data Set PRSB Record structure and content 2.16.840.1.113883.3.1937.777.28.1.1

Name Id
draft Cardiovascular Disease (GP) (2.1) 2.16.840.1.113883.3.1937.777.28.4.239
Version / effective date Expiration date
2021‑02‑08 13:33:56
Description
Name Details [‑]
folder draft Person demographics 1 … 1 Mandatory
prsb03-dataelement-10868
Id prsb03-dataelement-10868 (2019‑03‑27 19:02:25)
Cardinality 1 … 1 Mandatory
Description The person's details and contact information.
target Used by 15 transactions, 0 templates, inherited 0 times
 
folder draft Person name 1 … 1 Mandatory
prsb03-dataelement-10869
Id prsb03-dataelement-10869 (2019‑03‑27 19:05:18) 1
Cardinality 1 … 1 Mandatory
Description Details of the person's name
Relationship
target Used by 15 transactions, 0 templates, inherited 0 times
 
draft Person full name 1 … 1 Mandatory
prsb03-dataelement-13801
Id prsb03-dataelement-13801 (2020‑11‑09 17:03:29)
Cardinality 1 … 1 Mandatory
Description The full name of the person in text representation.
Rationale Patient.name.text
Operationalization NHS data dictionary :- Patient full name
Value Domain
Property
max length
70
target Used by 15 transactions, 0 templates, inherited 4 times
 
draft Date of birth 1 … 1 Mandatory
prsb03-dataelement-10871
Id prsb03-dataelement-10871 (2019‑03‑27 19:08:01) 1
Cardinality 1 … 1 Mandatory
Description The date of birth of the person.

Properties

FHIR Patient.birthDate
Relationship
Rationale Patient.birthdate
Source NHS NSS : - https://www.ndc.scot.nhs.uk/Dictionary-A-Z/Definitions/index.asp?Search=D&ID=186&Title=Date%20of%20Birth
Operationalization NHS data dictionary:- Person birth date
Value Domain
Property
Timestamp precision
day, month and year
target Used by 15 transactions, 0 templates, inherited 0 times
 
draft Gender 0 … 1
prsb03-dataelement-10872
Id prsb03-dataelement-10872 (2019‑03‑27 19:08:52) 1
Cardinality 0 … 1
Description The person's stated gender.

Properties

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

Value Domain
Property
max length
1
target Used by 15 transactions, 0 templates, inherited 0 times
 
draft Ethnicity 0 … 1
prsb03-dataelement-10874
Id prsb03-dataelement-10874 (2019‑03‑27 19:11:37) 1
Cardinality 0 … 1
Description The ethnicity of the person as specified by the person.
Relationship
Rationale Patient.extension(ethnicCategory)
Source NHS_Wales: https://fhir.standards.wales/CodeSystem/DataStandardsWales-Ethnicity

NHS_NSS: https://www.ndc.scot.nhs.uk/Dictionary-A-Z/Definitions/index.asp?Search=E&ID=243&Title=Ethnic%20Group
Operationalization NHS data dictionary :- Ethnic category
Value Domain
Property
max length
2
target Used by 5 transactions, 0 templates, inherited 0 times
 
draft NHS number 0 … 1
prsb03-dataelement-10879
Id prsb03-dataelement-10879 (2019‑03‑27 19:16:57) 1
Cardinality 0 … 1
Description The unique identifier for a person within the NHS in England and Wales.

Properties

FHIR Patient.identifier.nhsnumber
Relationship
Rationale Patient.identifier(nhsnumber)
Operationalization NHS data dictionary:- NHS number
Value Domain
Property
max length
10
target Used by 15 transactions, 0 templates, inherited 0 times
 
draft Other identifier 0 … *
prsb03-dataelement-10880
Id prsb03-dataelement-10880 (2019‑03‑27 19:18:59)
Cardinality 0 … *
Description Country specific or local identifier, e.g. Community Health Index (CHI) in Scotland.
Relationship
Rationale Patient.identifier
Operationalization
Value Domain
Property
max length
20
target Used by 15 transactions, 0 templates, inherited 0 times
 
folder draft Person's address 1 … 1 Mandatory
prsb03-dataelement-10881
Id prsb03-dataelement-10881 (2019‑03‑27 19:19:27)
Cardinality 1 … 1 Mandatory
Description Person’s usual place of residence, and where relevant temporary and correspondence addresses.

Properties

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

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

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

Value Domain
Property
max length
35
target Used by 15 transactions, 0 templates, inherited 0 times
 
draft Address line 5 0 … 1
prsb03-dataelement-13086
Id prsb03-dataelement-13086 (2020‑06‑01 11:32:10)
Cardinality 0 … 1
Description Person's fifth line of address.
Rationale Patient.address.country
Operationalization NHS data dictionary : - Address line 5

Value Domain
Property
max length
35
target Used by 15 transactions, 0 templates, inherited 0 times
 
draft Postcode 0 … 1
prsb03-dataelement-13087
Id prsb03-dataelement-13087 (2020‑06‑01 11:40:09)
Cardinality 0 … 1
Description The person's postcode.
Rationale Patient.address.postalcode
Operationalization NHS data dictionary :- Postcode of usual address

Value Domain
Property
max length
8
target Used by 15 transactions, 0 templates, inherited 0 times
 
folder draft Person's contact details 0 … *
prsb03-dataelement-13804
Id prsb03-dataelement-13804 (2020‑11‑25 18:32:36)
Cardinality 0 … *
Description Details of the person's contact information.
target Used by 15 transactions, 0 templates, inherited 0 times
 
folder draft Person's telephone number details 0 … *
prsb03-dataelement-10883
Id prsb03-dataelement-10883 (2019‑03‑27 19:22:39)
Cardinality 0 … *
Description The person's telephone number details

Properties

FHIR Patient.telecom
Relationship
target Used by 15 transactions, 0 templates, inherited 0 times
 
draft Person's telephone number 0 … 1
prsb03-dataelement-13808
Id prsb03-dataelement-13808 (2020‑11‑26 16:51:24)
Cardinality 0 … 1
Description The person's telephone number
Rationale Patient.contact.telecon.value
Operationalization NHS data dictionary : - UK telephone number
Value Domain
Property
max length
35
target Used by 15 transactions, 0 templates, inherited 0 times
 
draft Person's telephone number type 0 … 1
prsb03-dataelement-13805
Id prsb03-dataelement-13805 (2020‑11‑25 18:37:54)
Cardinality 0 … 1
Description The contact type e.g. home, mobile
Rationale Patient.telecon.use
Operationalization FHIR value set: - Contact point use
Value Domain
Property
max length
6
Example Home
Example Mobile
Example Temp
Example Old
Example Work
target Used by 15 transactions, 0 templates, inherited 0 times
 
draft Preference of telephone number 0 … 1
prsb03-dataelement-13809
Id prsb03-dataelement-13809 (2020‑11‑26 16:55:09)
Cardinality 0 … 1
Description The preferred order of use for the telephone number
Rationale Patient.telecom.rank
Operationalization Preference of use 1-5, 1 being the highest.
Value Domain
target Used by 15 transactions, 0 templates, inherited 0 times
 
folder draft GP practice 1 … 1 Mandatory
prsb03-dataelement-101
Id prsb03-dataelement-101 (2018‑10‑31)
Cardinality 1 … 1 Mandatory
Description Details of the person's GP practice.
target Used by 15 transactions, 0 templates, inherited 0 times
 
folder draft GP practice record entry 1 … *
prsb03-dataelement-10643
Id prsb03-dataelement-10643 (2018‑11‑09 14:59:24)
Cardinality 1 … *
Description This is an GP practice record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items
target Used by 15 transactions, 0 templates, inherited 0 times
 
draft GP practice identifier 1 … 1 Mandatory
prsb03-dataelement-10001
Id prsb03-dataelement-10001 (2018‑10‑31)
Cardinality 1 … 1 Mandatory
Description The identifier of the registered GP practice.

Properties

FHIR Sliced into ODS and local identifier. PratitionerRole.organisation.identifier
Rationale PratitionerRole.organisation.identifier
Operationalization
Value Domain
Property
max length
6
target Used by 15 transactions, 0 templates, inherited 0 times
 
folder draft Legal information 0 … 1
prsb03-dataelement-520
Id prsb03-dataelement-520 (2018‑10‑31)
Cardinality 0 … 1
Description The legal information relating to the person.
target Used by 14 transactions, 0 templates, inherited 0 times
 
folder draft Consent for treatment record 0 … 1
prsb03-dataelement-10420
Id prsb03-dataelement-10420 (2018‑10‑31)
Cardinality 0 … 1
Description Details of the person's consent for treatment.
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Date 0 … 1
prsb03-dataelement-13457
Id prsb03-dataelement-13457 (2020‑09‑02 12:31:32)
Cardinality 0 … 1
Description The date the consent was taken
Operationalization Date
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
target Used by 14 transactions, 0 templates, inherited 0 times
 
folder draft Location 0 … 1
prsb03-dataelement-13459
Id prsb03-dataelement-13459 (2020‑09‑02 12:33:42)
Cardinality 0 … 1
Description The location of where the consent was taken.
Relationship
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Coded value 0 … 1
prsb03-dataelement-13460
Id prsb03-dataelement-13460 (2020‑09‑02 12:34:21)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13242 (2020‑07‑27 18:27:08)
Description The coded value for location.
Operationalization NHS data dictionary : - Organisation data service code
Value Domain
Property
min length max length
3 5
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Free text 0 … 1
prsb03-dataelement-13461
Id prsb03-dataelement-13461 (2020‑09‑02 12:34:21)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13243 (2020‑07‑27 18:31:13)
Description Free text field to be used if no code is available
Operationalization Free text
Value Domain
Property
max length
150
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Consent for treatment record 0 … 1
prsb03-dataelement-13574
Id prsb03-dataelement-13574 (2020‑09‑07 16:40:51)
Cardinality 0 … 1
Description Whether consent has been obtained for the treatment. May include where record of consent is located or record of consent. A statement about the patient's consent for treatment.
Operationalization Free text
Value Domain
Property
max length
150
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Location of document 0 … 1
prsb03-dataelement-13777
Id prsb03-dataelement-13777 (2020‑10‑16 16:32:46)
Cardinality 0 … 1
Description The location of the consent for treatment record.
Relationship
Operationalization Free text or URL
Value Domain
Property
max length
150
target Used by 14 transactions, 0 templates, inherited 0 times
 
folder draft Performing professional 0 … 1
prsb03-dataelement-13462
Id prsb03-dataelement-13462 (2020‑09‑02 12:35:54)
Cardinality 0 … 1
Description The professional who took the consent for treatment.
Relationship
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Name 0 … 1
prsb03-dataelement-13463
Id prsb03-dataelement-13463 (2020‑09‑02 12:38:25)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-11735 (2019‑05‑31 13:23:55)
Description The name of the professional.
Rationale Practitioner.name
Operationalization Free text.
Value Domain
Property
max length
70
target Used by 14 transactions, 0 templates, inherited 2 times
 
draft Role 0 … 1
prsb03-dataelement-13464
Id prsb03-dataelement-13464 (2020‑09‑02 12:38:25)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-11736 (2019‑05‑31 13:23:55)
Description The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc
Rationale Practitioner.PractitionerRole.code
Operationalization FHIR value set :- SDSjobroletype
Value Domain
target Used by 14 transactions, 0 templates, inherited 2 times
 
draft Grade 0 … 1
prsb03-dataelement-13465
Id prsb03-dataelement-13465 (2020‑09‑02 12:38:25)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-11737 (2019‑05‑31 13:23:55)
Description The grade of the professional.
Rationale PractitionerRole.code
Operationalization Free text
Value Domain
Property
max length
150
target Used by 14 transactions, 0 templates, inherited 2 times
 
draft Speciality 0 … 1
prsb03-dataelement-13466
Id prsb03-dataelement-13466 (2020‑09‑02 12:38:25)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-11738 (2019‑05‑31 13:23:55)
Description The specialty of the professional e.g. physiotherapy, oncology, mental health etc
Rationale PractitionerRole.speciality
Operationalization NHS data dictionary - Activity treatment function code
Value Domain
Property
max length
3
target Used by 14 transactions, 0 templates, inherited 2 times
 
draft Professional identifier 0 … 1
prsb03-dataelement-13467
Id prsb03-dataelement-13467 (2020‑09‑02 12:38:25)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-11739 (2019‑05‑31 13:23:55)
Description Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.
Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
Operationalization NHS data dictionary : - Professional registration identifier
Value Domain
Property
max length
32
target Used by 14 transactions, 0 templates, inherited 2 times
 
folder draft Organisation 0 … 1
prsb03-dataelement-13468
Id prsb03-dataelement-13468 (2020‑09‑02 12:38:25)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-11740 (2019‑05‑31 13:23:55)
Description The name of the organisation the professional works for.
target Used by 14 transactions, 0 templates, inherited 2 times
 
draft Contact details 0 … 1
prsb03-dataelement-13469
Id prsb03-dataelement-13469 (2020‑09‑02 12:38:25)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-11741 (2019‑05‑31 13:23:55)
Description Contact details of the professional
Rationale Practitioner.telecom

PractitionerRole.telecom

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

Properties

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

Properties

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

Properties

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

Properties

FHIR PractitionerRole.telecom
Relationship
Rationale Practitioner.telecom

PractitionerRole.telecom

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

PractitionerRole.telecom

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

Properties

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

Properties

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

Properties

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

Properties

FHIR PractitionerRole.telecom
Relationship
Rationale Practitioner.telecom

PractitionerRole.telecom

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

PractitionerRole.telecom

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

Properties

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

Properties

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

Properties

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

Properties

FHIR PractitionerRole.telecom
Relationship
Rationale Practitioner.telecom

PractitionerRole.telecom

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

Properties

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

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

Properties

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

Properties

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

Properties

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



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

Properties

FHIR Encounter.participant
Operationalization NHS data dictionary : - Person full name
Value Domain
Property
max length
70
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Organisation name 1 … 1 Mandatory
prsb03-dataelement-10706
Id prsb03-dataelement-10706 (2018‑12‑04 15:30:13)
Cardinality 1 … 1 Mandatory
Description The name, including the identifier, of the organisation providing the service
Operationalization NHS data dictionary : - Organisation name
Value Domain
Property
max length
255
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Organisation address 0 … 1
prsb03-dataelement-10713
Id prsb03-dataelement-10713 (2018‑12‑04 15:37:02)
Cardinality 0 … 1
Description The name of the organisation, including the identifier.
Operationalization NHS data dictionary : - Organisation address
Value Domain
Property
max length
175
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Organisation contact details 0 … *
prsb03-dataelement-10707
Id prsb03-dataelement-10707 (2018‑12‑04 15:31:05)
Cardinality 0 … *
Description The contact details of the organisation. For example a phone number, NHSmail address etc. Contact details are used to resolve queries about the record entry.
Operationalization Free text
Value Domain
Property
max length
150
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Reason for non-provision of service 0 … 1
prsb03-dataelement-10708
Id prsb03-dataelement-10708 (2018‑12‑04 15:31:26)
Cardinality 0 … 1
Description The reason why the patient was not provided with the service e.g. declined, did not attend etc.
Operationalization Free text
Value Domain
Property
max length
150
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Clinician name 1 … 1 Mandatory
prsb03-dataelement-10709
Id prsb03-dataelement-10709 (2018‑12‑04 15:31:49)
Cardinality 1 … 1 Mandatory
Description The name of the person providing the service.
Operationalization Free text
Value Domain
Property
max length
70
target Used by 13 transactions, 0 templates, inherited 0 times
 
draft Role 0 … 1
prsb03-dataelement-10710
Id prsb03-dataelement-10710 (2018‑12‑04 15:32:09)
Cardinality 0 … 1
Description The role of the person providing the service.
Operationalization FHIR values set : - sdsjobrole
Value Domain
target Used by 13 transactions, 0 templates, inherited 3 times
 
draft Chaperone 0 … *
prsb03-dataelement-10712
Id prsb03-dataelement-10712 (2018‑12‑04 15:33:12)
Cardinality 0 … *
Description The name of any chaperone(s).
Operationalization Free text
Value Domain
Property
max length
70
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Professional identifier 0 … 1
prsb03-dataelement-10711
Id prsb03-dataelement-10711 (2018‑12‑04 15:32:25)
Cardinality 0 … 1
Description Professional identifier of the person providing the service.
Operationalization NHS data dictionary : - professional identifier
Value Domain
Property
max length
32
target Used by 14 transactions, 0 templates, inherited 0 times
 
folder draft History 0 … 1
prsb03-dataelement-226
Id prsb03-dataelement-226 (2018‑10‑31)
Cardinality 0 … 1
Description History
target Used by 14 transactions, 0 templates, inherited 0 times
 
folder draft Relevant past medical, surgical and mental health history 0 … 1
prsb03-dataelement-10130
Id prsb03-dataelement-10130 (2018‑10‑31)
Cardinality 0 … 1
Description The record of the person’s significant medical, surgical and mental health history. Including relevant previous diagnoses, problems and issues, procedures, investigations, specific anesthesia issues, etc. (will include dental and obstetric history)

A list of the person's relevant past medical, surgical and mental health history recorded in free text or coded form or Information relating to past medical, surgical and mental health history may be provided by the referral document or during the consultation.
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Coded value 0 … 1
prsb03-dataelement-13787
Id prsb03-dataelement-13787 (2020‑10‑22 17:51:01)
Cardinality 0 … 1
notice There is an open issue with this item:
Description The coded value relevant past medical, surgical and mental health history
Operationalization SNOMED CT : -  ^1127581000000103 |Health issues simple reference set|
Value Domain
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Free text 0 … 1
prsb03-dataelement-13788
Id prsb03-dataelement-13788 (2020‑10‑22 17:53:28)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13450 (2020‑08‑27 16:43:57)
Description Free text field to be used if no code is available
Operationalization Free text
Value Domain
Property
max length
150
target Used by 14 transactions, 0 templates, inherited 0 times
 
folder draft Clinical Summary 1 … 1 Mandatory
prsb03-dataelement-247
Id prsb03-dataelement-247 (2018‑10‑31)
Cardinality 1 … 1 Mandatory
Description Clinical Summary
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Clinical narrative 1 … 1 Mandatory
prsb03-dataelement-10150
Id prsb03-dataelement-10150 (2018‑10‑31)
Cardinality 1 … 1 Mandatory
Description A description detailing a patient’s reason for attendance, results from the diagnostic and treatment process.
Operationalization Free text
Value Domain
target Used by 14 transactions, 0 templates, inherited 0 times
 
folder draft Social context 0 … 1
prsb03-dataelement-136
Id prsb03-dataelement-136 (2018‑10‑31)
Cardinality 0 … 1
Description The social setting in which the person lives, such as their household, occupational history, and lifestyle factors.
target Used by 5 transactions, 0 templates, inherited 0 times
 
folder draft Smoking status 0 … 1
prsb03-dataelement-10040
Id prsb03-dataelement-10040 (2018‑10‑31)
Cardinality 0 … 1
Description Details of the person's smoking status.

Properties

FHIR Observation.category Observation.code Observation.valueCodeabelConcept Observation.subject
target Used by 5 transactions, 0 templates, inherited 0 times
 
folder draft Smoking status 0 … 1
prsb03-dataelement-13283
Id prsb03-dataelement-13283 (2020‑07‑30 17:12:22)
Cardinality 0 … 1
Description
Record of any smoking use by the person.
target Used by 5 transactions, 0 templates, inherited 0 times
 
draft Coded value 0 … 1
prsb03-dataelement-13284
Id prsb03-dataelement-13284 (2020‑07‑30 17:14:44)
Cardinality 0 … 1
Description The smoking status of the person.
Operationalization SNOMED CT:- ^999000891000000102 |Smoking simple reference set (foundation metadata concept)|
Value Domain
target Used by 5 transactions, 0 templates, inherited 0 times
 
draft Free text 0 … 1
prsb03-dataelement-13285
Id prsb03-dataelement-13285 (2020‑07‑30 17:16:04)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
Description Free text field to be used if no code is available
Operationalization Free text
Value Domain
Property
max length
150
target Used by 5 transactions, 0 templates, inherited 0 times
 
draft Smoking status - details 0 … 1
prsb03-dataelement-13286
Id prsb03-dataelement-13286 (2020‑07‑31 15:58:03)
Cardinality 0 … 1
Description Further details recorded about the smoking status of the person
Operationalization Free text
Value Domain
Property
max length
150
target Used by 5 transactions, 0 templates, inherited 0 times
 
folder draft Smoking record 1 … 1
prsb03-dataelement-12489
Id prsb03-dataelement-12489 (2019‑10‑29 14:19:57)
Cardinality 1 … 1
Description Details of the person's smoking record
target Used by one transaction, 0 templates, inherited once
 
draft Overall smoking status 1 … 1 Mandatory
prsb03-dataelement-12490
Id prsb03-dataelement-12490 (2019‑10‑29 14:22:56) 0.1
Cardinality 1 … 1 Mandatory
Description

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

Defined by current smoking status and ever smoking status.

Operationalization

Coded text:

Current Smoker

Former Smoker

Never Smoked

^999000891000000102 |Smoking simple reference set (foundation metadata concept)|
Value Domain
target Used by one transaction, 0 templates, inherited once
 
draft Date of quitting 0 … 1
prsb03-dataelement-12491
Id prsb03-dataelement-12491 (2019‑10‑29 14:35:16)
Cardinality 0 … 1
Description Date when the individual stopped smoking (if a former smoker).
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year
target Used by one transaction, 0 templates, inherited once
 
folder draft Alcohol record 0 … 1
prsb03-dataelement-12498
Id prsb03-dataelement-12498 (2019‑10‑29 16:51:15)
Cardinality 0 … 1
Description Details of a person's alcohol record
target Used by 2 transactions, 0 templates, inherited 0 times
 
folder draft Audit questionnaire 0 … 1
prsb03-dataelement-12499
Id prsb03-dataelement-12499 (2019‑10‑29 16:52:18)
Cardinality 0 … 1
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]
target Used by 2 transactions, 0 templates, inherited 0 times
 
draft Date 1 … 1 Mandatory
prsb03-dataelement-12524
Id prsb03-dataelement-12524 (2019‑10‑29 17:53:29)
Cardinality 1 … 1 Mandatory
Description

Date of person's AUDIT questionnaire.
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year
target Used by 2 transactions, 0 templates, inherited 0 times
 
folder draft AUDIT-C cluster 0 … 1
prsb03-dataelement-12500
Id prsb03-dataelement-12500 (2019‑10‑29 16:55:54)
Cardinality 0 … 1
Description

AUDIT-C questions: Frequency of consumption, Typical consumption, Binge drinking.
target Used by 2 transactions, 0 templates, inherited 0 times
 
draft Frequency of consumption 1 … 1 Mandatory
prsb03-dataelement-12501
Id prsb03-dataelement-12501 (2019‑10‑29 16:57:59)
Cardinality 1 … 1 Mandatory
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
target Used by 2 transactions, 0 templates, inherited 0 times
 
folder draft Typical consumption cluster 1 … 1 Mandatory
prsb03-dataelement-12502
Id prsb03-dataelement-12502 (2019‑10‑29 17:00:28)
Cardinality 1 … 1 Mandatory
Description Details of the person's typical consumption
target Used by 2 transactions, 0 templates, inherited 0 times
 
draft Absolute value 1 … 1 Mandatory
prsb03-dataelement-12503
Id prsb03-dataelement-12503 (2019‑10‑29 17:02:06)
Cardinality 1 … 1 Mandatory
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
target Used by 2 transactions, 0 templates, inherited 0 times
 
draft Categorical value 1 … 1 Mandatory
prsb03-dataelement-12504
Id prsb03-dataelement-12504 (2019‑10‑29 17:04:12)
Cardinality 1 … 1 Mandatory
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
target Used by 2 transactions, 0 templates, inherited 0 times
 
draft Binge drinking 1 … 1 Mandatory
prsb03-dataelement-12505
Id prsb03-dataelement-12505 (2019‑10‑29 17:05:54)
Cardinality 1 … 1 Mandatory
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
target Used by 2 transactions, 0 templates, inherited 0 times
 
draft AUDIT-C total score 1 … 1 Mandatory
prsb03-dataelement-12525
Id prsb03-dataelement-12525 (2019‑10‑31 13:52:46)
Cardinality 1 … 1 Mandatory
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
target Used by 2 transactions, 0 templates, inherited 0 times
 
folder draft if AUDIT-C score >=5 0 … *
prsb03-dataelement-12507
Id prsb03-dataelement-12507 (2019‑10‑29 17:08:20)
Cardinality 0 … *
Description Populate this section if the AUDIT-C score is >=5.
target Used by 2 transactions, 0 templates, inherited 0 times
 
draft Inability to stop 0 … 1
prsb03-dataelement-12511
Id prsb03-dataelement-12511 (2019‑10‑29 17:17:08)
Cardinality 0 … 1
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
target Used by 2 transactions, 0 templates, inherited 0 times
 
draft Failed expectations 0 … *
prsb03-dataelement-12512
Id prsb03-dataelement-12512 (2019‑10‑29 17:18:25)
Cardinality 0 … *
Description

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

Value Domain
target Used by 2 transactions, 0 templates, inherited 0 times
 
draft Morning drinking 0 … 1
prsb03-dataelement-12513
Id prsb03-dataelement-12513 (2019‑10‑29 17:19:40)
Cardinality 0 … 1
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
target Used by 2 transactions, 0 templates, inherited 0 times
 
draft Guilt/remorse 0 … 1
prsb03-dataelement-12514
Id prsb03-dataelement-12514 (2019‑10‑29 17:21:13)
Cardinality 0 … 1
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
target Used by 2 transactions, 0 templates, inherited 0 times
 
draft Loss of memory 0 … 1
prsb03-dataelement-12515
Id prsb03-dataelement-12515 (2019‑10‑29 17:22:19)
Cardinality 0 … 1
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
target Used by 2 transactions, 0 templates, inherited 0 times
 
draft Injuries 0 … 1
prsb03-dataelement-12516
Id prsb03-dataelement-12516 (2019‑10‑29 17:23:40)
Cardinality 0 … 1
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
target Used by 2 transactions, 0 templates, inherited 0 times
 
draft External concern 0 … 1
prsb03-dataelement-12517
Id prsb03-dataelement-12517 (2019‑10‑29 17:27:36)
Cardinality 0 … 1
Description

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

Value Domain
target Used by 2 transactions, 0 templates, inherited 0 times
 
draft AUDIT total score 0 … 1
prsb03-dataelement-12518
Id prsb03-dataelement-12518 (2019‑10‑29 17:32:10)
Cardinality 0 … 1
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
target Used by 2 transactions, 0 templates, inherited 0 times
 
folder draft Family history 0 … 1
prsb03-dataelement-251
Id prsb03-dataelement-251 (2018‑10‑31)
Cardinality 0 … 1
Description Family history
target Used by 3 transactions, 0 templates, inherited 0 times
 
folder draft Family history record entry 0 … *
prsb03-dataelement-10653
Id prsb03-dataelement-10653 (2018‑11‑13 12:07:47)
Cardinality 0 … *
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.
target Used by 3 transactions, 0 templates, inherited 0 times
 
folder draft Family history 0 … 1
prsb03-dataelement-10151
Id prsb03-dataelement-10151 (2018‑10‑31)
Cardinality 0 … 1
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.
target Used by 3 transactions, 0 templates, inherited 0 times
 
draft Coded value 0 … 1
prsb03-dataelement-13678
Id prsb03-dataelement-13678 (2020‑09‑09 12:35:18)
Cardinality 0 … 1
Description The coded value for family history
Operationalization SNOMED CT:- <404684003 |Clinical finding (finding)| OR <243796009 |Situation with explicit context (situation)|

Value Domain
target Used by 3 transactions, 0 templates, inherited 0 times
 
draft Free text 0 … 1
prsb03-dataelement-13679
Id prsb03-dataelement-13679 (2020‑09‑09 12:38:35)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13223 (2020‑07‑08 17:40:09)
Description Free text field to be used if no coded text available
Value Domain
Property
max length
150
target Used by 3 transactions, 0 templates, inherited 0 times
 
folder draft Investigation results 0 … 1
prsb03-dataelement-257
Id prsb03-dataelement-257 (2018‑10‑31)
Cardinality 0 … 1
Description Investigation results
target Used by 5 transactions, 0 templates, inherited 0 times
 
folder draft Investigation results record entry 0 … *
prsb03-dataelement-10654
Id prsb03-dataelement-10654 (2018‑11‑13 12:10:48)
Cardinality 0 … *
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.
target Used by 5 transactions, 0 templates, inherited 0 times
 
draft Date 0 … 1
prsb03-dataelement-10157
Id prsb03-dataelement-10157 (2018‑10‑31)
Cardinality 0 … 1
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
target Used by 5 transactions, 0 templates, inherited 0 times
 
folder draft Investigation 1 … 1 Mandatory
prsb03-dataelement-10160
Id prsb03-dataelement-10160 (2018‑10‑31)
Cardinality 1 … 1 Mandatory
Description The investigation performed.
target Used by 5 transactions, 0 templates, inherited 0 times
 
draft Coded value 0 … 1
prsb03-dataelement-13525
Id prsb03-dataelement-13525 (2020‑09‑04 14:11:36)
Cardinality 0 … 1
Description The coded value for investigation
Operationalization SNOMED CT: - <71388002 |Procedure (procedure)|

Value Domain
target Used by 5 transactions, 0 templates, inherited 0 times
 
draft Free text 0 … 1
prsb03-dataelement-13526
Id prsb03-dataelement-13526 (2020‑09‑04 14:22:43)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
Description Free text field to be used if no code is available
Operationalization Free text
Value Domain
Property
max length
150
target Used by 5 transactions, 0 templates, inherited 0 times
 
folder draft Investigation result 0 … 1
prsb03-dataelement-10161
Id prsb03-dataelement-10161 (2018‑10‑31)
Cardinality 0 … 1
Description For each investigation, the result of the investigation. This can include a report which may have results for multiple tests.
target Used by 5 transactions, 0 templates, inherited 0 times
 
draft Coded value 0 … 1
prsb03-dataelement-13527
Id prsb03-dataelement-13527 (2020‑09‑04 14:25:41)
Cardinality 0 … 1
Description The coded value for investigation results
Operationalization SNOMED CT:- <404684003 |Clinical finding (finding)| OR <243796009 |Situation with explicit context (situation)|

Value Domain
target Used by 5 transactions, 0 templates, inherited 0 times
 
draft Free text 0 … 1
prsb03-dataelement-13528
Id prsb03-dataelement-13528 (2020‑09‑04 14:29:50)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
Description Free text field to be used if no code is available
Operationalization Free text
Value Domain
Property
max length
150
target Used by 5 transactions, 0 templates, inherited 0 times
 
draft Investigation Method 0 … 1
prsb03-dataelement-14094
Id prsb03-dataelement-14094 (2021‑02‑18 13:46:34)
Cardinality 0 … 1
Description Method used in carrying out investigation
Operationalization Coded entry - Point of care test, Laboratory test
Value Domain
target Used by 5 transactions, 0 templates, inherited 0 times
 
folder draft Structured investigation result 0 … 1
prsb03-dataelement-12415
Id prsb03-dataelement-12415 (2019‑06‑07 16:21:34)
Cardinality 0 … 1
Description A structured set of information for each investigation result.
target Used by 5 transactions, 0 templates, inherited 0 times
 
draft Value 0 … 1
prsb03-dataelement-12416
Id prsb03-dataelement-12416 (2019‑06‑07 16:22:08)
Cardinality 0 … 1
Description The value of the investigation result.
Operationalization Numeric
Value Domain
Property
max length
10
target Used by 5 transactions, 0 templates, inherited 0 times
 
draft Units of measure 0 … 1
prsb03-dataelement-12417
Id prsb03-dataelement-12417 (2019‑06‑07 16:23:50)
Cardinality 0 … 1
Description The units of the investigation result.
Operationalization UCUM code
Value Domain
Property
max length
10
target Used by 5 transactions, 0 templates, inherited 0 times
 
draft Reference ranges 0 … 1
prsb03-dataelement-12418
Id prsb03-dataelement-12418 (2019‑06‑07 16:24:48)
Cardinality 0 … 1
Description The reference range for the investigation result.
Operationalization Free text
Value Domain
target Used by 5 transactions, 0 templates, inherited 0 times
 
draft Abnormal indicator 0 … 1
prsb03-dataelement-12419
Id prsb03-dataelement-12419 (2019‑06‑07 16:26:00)
Cardinality 0 … 1
Description Indicator if the investigation is abnormal.
Operationalization Abnormal or Normal
Value Domain
target Used by 5 transactions, 0 templates, inherited 0 times
 
folder draft Signpost details 0 … 1
prsb03-dataelement-13973
Id prsb03-dataelement-13973 (2021‑02‑11 12:24:29)
Cardinality 0 … 1
Description Details of signpost
target Used by 14 transactions, 0 templates, inherited 0 times
 
folder draft Signpost details record entry 0 … *
prsb03-dataelement-13974
Id prsb03-dataelement-13974 (2021‑02‑11 12:26:44)
Cardinality 0 … *
Description This is the signpost details record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Date 0 … 1
prsb03-dataelement-13975
Id prsb03-dataelement-13975 (2021‑02‑11 12:28:32)
Cardinality 0 … 1
Description Date of signpost
Value Domain
Property
Timestamp precision
at least day, month and year
target Used by 14 transactions, 0 templates, inherited 0 times
 
folder draft Signpost to 0 … 1
prsb03-dataelement-13976
Id prsb03-dataelement-13976 (2021‑02‑11 12:29:57)
Cardinality 0 … 1
Description Details of where the signpost is to.


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

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

Free text
target Used by 14 transactions, 0 templates, inherited 0 times
 
folder draft Examination findings 0 … 1
prsb03-dataelement-557
Id prsb03-dataelement-557 (2018‑10‑31)
Cardinality 0 … 1
Description Examination findings
target Used by 6 transactions, 0 templates, inherited 0 times
 
folder draft Examination findings record entry 0 … *
prsb03-dataelement-10662
Id prsb03-dataelement-10662 (2018‑11‑13 13:47:29)
Cardinality 0 … *
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.
target Used by 6 transactions, 0 templates, inherited 0 times
 
draft Date 0 … 1
prsb03-dataelement-10462
Id prsb03-dataelement-10462 (2018‑10‑31)
Cardinality 0 … 1
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
target Used by 6 transactions, 0 templates, inherited 0 times
 
folder draft Observations 0 … 1
prsb03-dataelement-10464
Id prsb03-dataelement-10464 (2018‑10‑31)
Cardinality 0 … 1
Description The record of essential physiological measurements, e.g., heart rate, blood pressure, temperature, pulse, height, weight, respiratory rate, oxygen saturation.
target Used by 6 transactions, 0 templates, inherited 0 times
 
folder draft Height/length 0 … 1
prsb03-dataelement-13761
Id prsb03-dataelement-13761 (2020‑09‑29 17:39:18)
Cardinality 0 … 1
Description The person's height and length measurement
target Used by 5 transactions, 0 templates, inherited 0 times
 
draft Coded value 0 … 1
prsb03-dataelement-13812
Id prsb03-dataelement-13812 (2020‑12‑16 15:09:39)
Cardinality 0 … 1
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
target Used by 5 transactions, 0 templates, inherited 0 times
 
draft Value 0 … 1
prsb03-dataelement-13813
Id prsb03-dataelement-13813 (2020‑12‑16 15:51:30)
Cardinality 0 … 1
Description The value of the observation.
Operationalization Numeric
Value Domain
Property
3
target Used by 5 transactions, 0 templates, inherited 0 times
 
draft Units of measure 0 … 1
prsb03-dataelement-13817
Id prsb03-dataelement-13817 (2020‑12‑18 17:57:29)
Cardinality 0 … 1
Description The units of measure for height/length
Operationalization UCUM code
Value Domain
Property
max length
10
target Used by 5 transactions, 0 templates, inherited 0 times
 
folder draft Weight 0 … 1
prsb03-dataelement-13814
Id prsb03-dataelement-13814 (2020‑12‑18 16:56:16)
Cardinality 0 … 1
Description The person's weight in kgs
target Used by 5 transactions, 0 templates, inherited 0 times
 
draft Coded value 0 … 1
prsb03-dataelement-13815
Id prsb03-dataelement-13815 (2020‑12‑18 17:03:24)
Cardinality 0 … 1
Description The coded value of weight
Operationalization SNOMED CT : - 27113001 |Body weight (observable entity)|
Value Domain
target Used by 5 transactions, 0 templates, inherited 0 times
 
draft Value 0 … 1
prsb03-dataelement-13816
Id prsb03-dataelement-13816 (2020‑12‑18 17:06:19)
Cardinality 0 … 1
Description The value of the person's weight
Operationalization Numeric
Value Domain
target Used by 5 transactions, 0 templates, inherited 0 times
 
draft Units of measure 0 … 1
prsb03-dataelement-13818
Id prsb03-dataelement-13818 (2020‑12‑18 17:59:33)
Cardinality 0 … 1
Description The units of measure for weight
Relationship
Operationalization UCUM code
Value Domain
Property
max length
10
target Used by 5 transactions, 0 templates, inherited 0 times
 
folder draft BMI 0 … 1
prsb03-dataelement-13819
Id prsb03-dataelement-13819 (2020‑12‑18 18:18:02)
Cardinality 0 … 1
Description The person's BMI calculation
target Used by 5 transactions, 0 templates, inherited 0 times
 
draft Coded value 0 … 1
prsb03-dataelement-13820
Id prsb03-dataelement-13820 (2020‑12‑18 18:18:45)
Cardinality 0 … 1
Description The coded value of BMI
Operationalization SNOMED CT: - 60621009 |Body mass index (observable entity)|
Value Domain
target Used by 5 transactions, 0 templates, inherited 0 times
 
draft Value 0 … 1
prsb03-dataelement-13821
Id prsb03-dataelement-13821 (2020‑12‑18 18:20:35)
Cardinality 0 … 1
Description The value of the person's BMI
Operationalization Numeric
Value Domain
Property
2
target Used by 5 transactions, 0 templates, inherited 0 times
 
draft Units of measure 0 … 1
prsb03-dataelement-13822
Id prsb03-dataelement-13822 (2020‑12‑18 18:22:30)
Cardinality 0 … 1
Description The units of measure for BMI
Operationalization UCUM code
Value Domain
Property
max length
10
target Used by 5 transactions, 0 templates, inherited 0 times
 
folder draft Blood pressure 0 … 1
prsb03-dataelement-13823
Id prsb03-dataelement-13823 (2020‑12‑18 18:52:08)
Cardinality 0 … 1
Description The person's blood pressure measurement
target Used by 6 transactions, 0 templates, inherited 0 times
 
folder draft Systolic blood pressure 0 … 1
prsb03-dataelement-13824
Id prsb03-dataelement-13824 (2020‑12‑18 18:53:17)
Cardinality 0 … 1
Description Details of the person's systolic blood pressure
target Used by 6 transactions, 0 templates, inherited 0 times
 
draft Coded value 0 … 1
prsb03-dataelement-13825
Id prsb03-dataelement-13825 (2020‑12‑18 18:54:13)
Cardinality 0 … 1
Description The coded value for systolic blood pressure
Operationalization SNOMED CT : - <<271649006 |Systolic blood pressure (observable entity)|

Value Domain
target Used by 6 transactions, 0 templates, inherited 0 times
 
draft Value 0 … 1
prsb03-dataelement-13826
Id prsb03-dataelement-13826 (2020‑12‑18 18:55:32)
Cardinality 0 … 1
Description The value of the systolic blood pressure reading
Operationalization Numeric
Value Domain
Property
3
target Used by 6 transactions, 0 templates, inherited 0 times
 
draft Units of measure 0 … 1
prsb03-dataelement-13827
Id prsb03-dataelement-13827 (2020‑12‑18 18:58:12)
Cardinality 0 … 1
Description The units of measure for systolic blood pressure
Operationalization UCUM code
Value Domain
Property
max length
10
target Used by 6 transactions, 0 templates, inherited 0 times
 
folder draft Site 0 … 1
prsb03-dataelement-13829
Id prsb03-dataelement-13829 (2020‑12‑18 19:10:44)
Cardinality 0 … 1
Description The anatomical site at which the blood pressure is taken

Properties

FHIR MedicationStatement.dosage.site
Relationship
target Used by 6 transactions, 0 templates, inherited 0 times
 
draft Coded value 0 … 1
prsb03-dataelement-13830
Id prsb03-dataelement-13830 (2020‑12‑18 19:11:37)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13657 (2020‑09‑08 20:33:18)
Description The coded value for site
Operationalization SNOMED CT: - <442083009 | Anatomical or acquired body structure (body structure) |

Value Domain
target Used by 6 transactions, 0 templates, inherited 0 times
 
draft Free text 0 … 1
prsb03-dataelement-13831
Id prsb03-dataelement-13831 (2020‑12‑18 19:11:37)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13658 (2020‑09‑08 20:35:42)
Description Free text field to be used when code is not available
Relationship
Operationalization Free text
Value Domain
Property
max length
150
target Used by 6 transactions, 0 templates, inherited 0 times
 
folder draft Diastolic blood pressure 0 … 1
prsb03-dataelement-13867
Id prsb03-dataelement-13867 (2021‑01‑27 18:37:13)
Cardinality 0 … 1
target Used by 6 transactions, 0 templates, inherited 0 times
 
draft Coded value 0 … 1
prsb03-dataelement-13868
Id prsb03-dataelement-13868 (2021‑01‑27 18:38:53)
Cardinality 0 … 1
Description The coded value for diastolic blood pressure.
Operationalization SNOMED CT :- <<271650006 |Diastolic blood pressure (observable entity)|

Value Domain
target Used by 6 transactions, 0 templates, inherited 0 times
 
draft Value 0 … 1
prsb03-dataelement-13869
Id prsb03-dataelement-13869 (2021‑01‑27 18:42:21)
Cardinality 0 … 1
Description The value of the diastolic blood pressure reading
Operationalization Numeric
Value Domain
Property
3
target Used by 6 transactions, 0 templates, inherited 0 times
 
draft Units of measure 0 … 1
prsb03-dataelement-13870
Id prsb03-dataelement-13870 (2021‑01‑27 18:45:53)
Cardinality 0 … 1
Description The units of measure for the diastolic blood pressure
Relationship
Operationalization UCUM code
Value Domain
Property
max length
10
target Used by 6 transactions, 0 templates, inherited 0 times
 
folder draft Site 0 … 1
prsb03-dataelement-13871
Id prsb03-dataelement-13871 (2021‑01‑27 18:49:54)
Cardinality 0 … 1
Description The anatomical site at where the blood pressure is taken

Properties

FHIR MedicationStatement.dosage.site
Relationship
target Used by 6 transactions, 0 templates, inherited 0 times
 
draft Coded value 0 … 1
prsb03-dataelement-13872
Id prsb03-dataelement-13872 (2021‑01‑27 18:51:09)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13657 (2020‑09‑08 20:33:18)
Description The coded value for site
Operationalization SNOMED CT: - <442083009 | Anatomical or acquired body structure (body structure) |

Value Domain
target Used by 6 transactions, 0 templates, inherited 0 times
 
draft Free text 0 … 1
prsb03-dataelement-13873
Id prsb03-dataelement-13873 (2021‑01‑27 18:51:09)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13658 (2020‑09‑08 20:35:42)
Description Free text field to be used when code is not available
Relationship
Operationalization Free text
Value Domain
Property
max length
150
target Used by 6 transactions, 0 templates, inherited 0 times
 
folder draft Heart rate 0 … 1
prsb03-dataelement-13859
Id prsb03-dataelement-13859 (2021‑01‑27 17:25:40)
Cardinality 0 … 1
Description The beat of the heart as felt through the walls of a peripheral artery measured in bpm
target Used by 5 transactions, 0 templates, inherited 0 times
 
draft Coded value 0 … 1
prsb03-dataelement-13970
Id prsb03-dataelement-13970 (2021‑02‑09 14:55:17)
Cardinality 0 … 1
Description The coded value for heart rate
Operationalization SNOMED CT : - 364075005 | Heart rate (observable entity) |
Value Domain
target Used by 5 transactions, 0 templates, inherited 0 times
 
draft Value 0 … 1
prsb03-dataelement-13971
Id prsb03-dataelement-13971 (2021‑02‑09 14:58:01)
Cardinality 0 … 1
Description The numeric value of heart rate
Operationalization Numeric
Value Domain
Property
3
target Used by 5 transactions, 0 templates, inherited 0 times
 
draft Units of measure 0 … 1
prsb03-dataelement-13972
Id prsb03-dataelement-13972 (2021‑02‑09 15:39:37)
Cardinality 0 … 1
Description The units of measure for heart rate
Operationalization UCUM code
Value Domain
target Used by 5 transactions, 0 templates, inherited 0 times
 
folder draft Assessments 0 … 1
prsb03-dataelement-262
Id prsb03-dataelement-262 (2018‑10‑31)
Cardinality 0 … 1
Description Details of the person's assessments
target Used by 4 transactions, 0 templates, inherited 0 times
 
folder draft Assessments record entry 0 … *
prsb03-dataelement-11664
Id prsb03-dataelement-11664 (2019‑05‑30 19:29:51)
Cardinality 0 … *
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.
target Used by 4 transactions, 0 templates, inherited 0 times
 
draft Assessment scale 0 … 1
prsb03-dataelement-12962
Id prsb03-dataelement-12962 (2019‑11‑20 15:46:29)
Cardinality 0 … 1
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
target Used by 4 transactions, 0 templates, inherited 0 times
 
draft Date 0 … 1
prsb03-dataelement-10763
Id prsb03-dataelement-10763 (2019‑03‑18 13:51:22)
Cardinality 0 … 1
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
target Used by 4 transactions, 0 templates, inherited 0 times
 
draft Assessment type 0 … 1
prsb03-dataelement-10822
Id prsb03-dataelement-10822 (2019‑03‑21 12:55:22)
Cardinality 0 … 1
Description The type of the assessment e.g. social care needs assessment.
Operationalization Free text
Value Domain
Property
max length
150
target Used by 4 transactions, 0 templates, inherited 0 times
 
draft Assessment summary 0 … 1
prsb03-dataelement-10754
Id prsb03-dataelement-10754 (2019‑03‑07 18:21:12)
Cardinality 0 … 1
Description The summary of the assessment
Operationalization Free text
Value Domain
Property
max length
250
target Used by 4 transactions, 0 templates, inherited 0 times
 
folder draft Structured assessment 0 … 1
prsb03-dataelement-10655
Id prsb03-dataelement-10655 (2018‑11‑13 12:15:56)
Cardinality 0 … 1
Description Details of the structured assessment.
target Used by 4 transactions, 0 templates, inherited 0 times
 
draft Structured assessment name 0 … 1
prsb03-dataelement-11751
Id prsb03-dataelement-11751 (2019‑05‑31 13:52:26)
Cardinality 0 … 1
Description Structured assessment name e.g. New York Heart Failure, Glasgow Coma scale, Activities of Daily Living (ADL) etc.
Operationalization SNOMED CT
Value Domain
target Used by 4 transactions, 0 templates, inherited 0 times
 
draft Assessment score 0 … 1
prsb03-dataelement-10162
Id prsb03-dataelement-10162 (2018‑10‑31)
Cardinality 0 … 1
Description The structured assessment score.
Operationalization Free text.
Value Domain
target Used by 4 transactions, 0 templates, inherited 0 times
 
draft Assessment value 0 … 1
prsb03-dataelement-10163
Id prsb03-dataelement-10163 (2018‑10‑31)
Cardinality 0 … 1
Description The structured assessment value.
Operationalization Numeric
Value Domain
target Used by 4 transactions, 0 templates, inherited 0 times
 
draft Global score 0 … 1
prsb03-dataelement-10166
Id prsb03-dataelement-10166 (2018‑10‑31)
Cardinality 0 … 1
Description The total global score from the assessment.
Operationalization Free text
Value Domain
target Used by 4 transactions, 0 templates, inherited 0 times
 
draft Subscale score 0 … 1
prsb03-dataelement-10169
Id prsb03-dataelement-10169 (2018‑10‑31)
Cardinality 0 … 1
Description The subscale score of the structured assessment.
Operationalization Free text.
Value Domain
target Used by 4 transactions, 0 templates, inherited 0 times
 
draft Subscale value 0 … *
prsb03-dataelement-10170
Id prsb03-dataelement-10170 (2018‑10‑31)
Cardinality 0 … *
Description The subscale value of the structured assessment.
Operationalization Numeric
Value Domain
target Used by 4 transactions, 0 templates, inherited 0 times
 
folder draft Allergies and adverse reactions 0 … 1
prsb03-dataelement-282
Id prsb03-dataelement-282 (2018‑10‑31)
Cardinality 0 … 1
Description Allergies and adverse reactions
target Used by 12 transactions, 0 templates, inherited 0 times
 
folder draft Allergies and adverse reactions record entry 0 … *
prsb03-dataelement-10657
Id prsb03-dataelement-10657 (2018‑11‑13 12:23:03)
Cardinality 0 … *
Description This is a allergies and adverse reactions record entry. There may be 1 to many record entries under a section.

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

Properties

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

Properties

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

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

Properties

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

Properties

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

Properties

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

Properties

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

Properties

FHIR AllergyIntolerance.extension.evidence
Rationale AllergyIntolerance.extension.evidence
Operationalization Free text
Value Domain
Property
max length
150
target Used by 12 transactions, 0 templates, inherited 0 times
 
draft Date first experienced 0 … 1
prsb03-dataelement-10188
Id prsb03-dataelement-10188 (2018‑10‑31)
Cardinality 0 … 1
Description When the reaction was first experienced i.e this may not be the first this has happened. May be a date or partial date (e.g. year) or text (e.g. during childhood)

Properties

FHIR AllergyIntolerance.onset[x]
Rationale AllergyIntolerance.onset
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least year
target Used by 12 transactions, 0 templates, inherited 0 times
 
draft Allergy end date 0 … 1
prsb03-dataelement-14253
Id prsb03-dataelement-14253 (2021‑03‑04 13:29:34)
Cardinality 0 … 1
Description The date the allergy was diagnosed as ended
Operationalization Date and time 
Value Domain
Property
Timestamp precision
at least year
target Used by 12 transactions, 0 templates, inherited 0 times
 
folder draft Information and advice given 0 … 1
prsb03-dataelement-315
Id prsb03-dataelement-315 (2018‑10‑31)
Cardinality 0 … 1
Description Information and advice given
target Used by 14 transactions, 0 templates, inherited 0 times
 
draft Information and advice given 0 … *
prsb03-dataelement-10215
Id prsb03-dataelement-10215 (2018‑10‑31)
Cardinality 0 … *
notice There is an open issue with this item:
Description

The oral or written information or advice given to the patient, carer, other authorised representative, care professional or other third party. May include advice about actions related to medicines or other ongoing care activities on an ‘information prescription'. State here if there are concerns about the extent to which the patient and/or carer understand the information provided about diagnosis, prognosis and treatment.

Properties

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

Properties

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

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

Properties

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

Properties

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

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

Properties

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

Properties

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