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draft Scenario Core information standard 2.16.840.1.113883.3.1937.777.28.3.28

Name Details [‑]
draft Core information standard
prsb03-scenario-28
Version / effective date 2 - 2020‑09‑07 16:04:15
Description Logical model for core information standard
draft doublearrow Core information standard
prsb03-transaction-158link
Version / effective date 2 - 2020‑09‑07 16:04:15    
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draft rotate Core information standard
prsb03-transaction-159link
Version / effective date 2 - 2020‑09‑07 16:04:15    
Actor
stationary (organization) Shared care record
Associations
Contained concepts
Concept Card/Conf Id
folder Person demographics
1 … 1 Mandatory
prsb03-dataelement-10868link
The person's details and contact information.
treetree folder Person name
1 … 1 Mandatory
prsb03-dataelement-10869link
Details of the person's name
treeblank treetree draft  Person first name
1 … * Mandatory
prsb03-dataelement-13799link
The first name(s) of the person. This includes middle names.NHS data dictionary :- Person given name
treeblank treetree draft  Person family name
1 … * Mandatory
prsb03-dataelement-13800link
The family name or surname of the personNHS data dictionary : - Person family name
treeblank treetree draft  Person preferred name
0 … 1
prsb03-dataelement-10870link
The name by which a person wishes to be addressed. The preferred name volunteered by the person or a preferred name given by PDS that the person has asked to be called by.NHS data dictionary: - Person full name
treeblank treetree draft  Title
0 … 1
prsb03-dataelement-13089link
Person's titleNHS data dictionary: - Person title
treeblank treetree draft  Person name suffix
0 … *
prsb03-dataelement-13798link
A textual suffix that may be added to the end of a PERSON's name, for example, OBE, MBE, BSc, JP, GMNHS data dictionary: - Person suffix
treeblank treetree draft  Person full name
0 … 1
prsb03-dataelement-13801link
The full name of the person in text representation.NHS data dictionary :- Patient full name
treetree draft  Date of birth
1 … 1 Mandatory
prsb03-dataelement-10871link
The date of birth of the person.NHS data dictionary:- Person birth date
treetree draft  Gender
0 … 1
prsb03-dataelement-10872link
The person's stated gender.NHS data dictionary :- Person stated gender code
treetree draft  Ethnicity
0 … 1
prsb03-dataelement-10874link
The ethnicity of the person as specified by the person.NHS data dictionary :- Ethnic category
treetree draft  Religion
0 … 1
prsb03-dataelement-10876link
The religious affiliation as specified by the person. SNOMED_CT:- Religion
treetree draft  Sex
0 … 1
prsb03-dataelement-10877link
The person’s phenotypic sex. Determines how the person will be treated clinically.NHS data dictionary: - person phenotypic sex
treetree draft  NHS number
0 … 1
prsb03-dataelement-10879link
The unique identifier for a person within the NHS in England and Wales.NHS data dictionary:- NHS number
treetree draft  NHS number status indicator
0 … 1
prsb03-dataelement-13297link
Provides an indication of the reliability of an NHS Number.NHS data dictionary :- NHS number status indicator
treetree draft  Other identifier
0 … *
prsb03-dataelement-10880link
Country specific or local identifier, e.g. Community Health Index (CHI) in Scotland. NHS data dictionary: - Local patient identifier(extended), Health and care number (NI only), Community health index number (Scotland only)
treetree folder Person's address
1 … * Mandatory
prsb03-dataelement-10881link
Person’s usual place of residence, and where relevant temporary and correspondence addresses.
treeblank treetree draft  Address line 1
1 … 1 Mandatory
prsb03-dataelement-13082link
Person's first line of address. NHS data dictionary :-  Address line 1
treeblank treetree draft  Address line 2
0 … 1
prsb03-dataelement-13083link
Person's second line of address. NHS data dictionary :- Address line 2
treeblank treetree draft  Address line 3
0 … 1
prsb03-dataelement-13084link
Person's third line of address. NHS data dictionary : - Address line 3
treeblank treetree draft  Address line 4
0 … 1
prsb03-dataelement-13085link
Person's fourth line of address. NHS data dictionary : - Address line 4
treeblank treetree draft  Address line 5
0 … 1
prsb03-dataelement-13086link
Person's fifth line of address.NHS data dictionary : - Address line 5
treeblank treetree draft  Postcode
0 … 1
prsb03-dataelement-13087link
The person's postcode.NHS data dictionary :- Postcode of usual address
treeblank treetree draft  Address type
0 … 1
prsb03-dataelement-13221link
The type of address e.g. Main address, Temp addressNHS data dictionary : - Address association type
treetree folder Person's contact details
0 … 1
prsb03-dataelement-13804link
Details of the person's contact information.
treeblank treetree draft  Preferred contact method
0 … 1
prsb03-dataelement-10886link
Preferred contact method, e.g. email, letter, phone, text message etc.NHS data dictionary :- Communication contact method
treeblank treetree folder Person's telephone number details
0 … *
prsb03-dataelement-10883link
The person's telephone number details
treeblank treeblank treetree draft  Person's telephone number
0 … 1
prsb03-dataelement-13808link
The person's telephone numberNHS data dictionary : - UK telephone number
treeblank treeblank treetree draft  Person's telephone number type
0 … 1
prsb03-dataelement-13805link
The contact type e.g. home, mobileFHIR value set: - Contact point use
treeblank treeblank treetree draft  Preference of telephone number
0 … 1
prsb03-dataelement-13809link
The preferred order of use for the telephone numberPreference of use 1-5, 1 being the highest.
treeblank treetree folder Person's email address details
0 … *
prsb03-dataelement-13807link
Details of the person's email address
treeblank treeblank treetree draft  Person's email address
0 … 1
prsb03-dataelement-10882link
Email address of the person.NHS data dictionary :- Contact email address
treeblank treeblank treetree draft  Person's email address type
0 … 1
prsb03-dataelement-13811link
The type of email address, home, workFHIR value set: - Contact point use
treeblank treeblank treetree draft  Preference of email address
0 … 1
prsb03-dataelement-13810link
The preferred order of use of email addressPreference of use 1-5, 1 being the highest.
treeblank treetree draft  Other contact information
0 … 1
prsb03-dataelement-13806link
Contact details via fax, sms, urlNHS data dictionary:- Communication contact string
treetree draft  Photograph
0 … 1
prsb03-dataelement-13065link
A photograph of the person for identification and to show what the person looks like normally.Mulitmedia file
treetree draft  Place of birth
0 … 1
prsb03-dataelement-10884link
The country of birth of the person.NHS data dictionary :- Country code (birth)
treetree draft  Marital status
0 … 1
prsb03-dataelement-10885link
An indicator to identify the legal marital status of the person.NHS data dictionary :- Person marital status
treetree folder Immigration status
0 … 1
prsb03-dataelement-13293link
Include details of the immigration status of the person, their permissions to live and receive care and support in the UK e.g. asylum seeker, indefinite leave to remain in the UK. Include start date, end date and any comments.
treeblank treetree draft  Immigration status
0 … 1
prsb03-dataelement-13304link
Details of the immigration status of the person, their permissions to live and receive care and support in the UK e.g. asylum seeker, indefinite leave to remain in the UK.Code :- 1: Asylum Seeker; 2: Exceptional leave to remain in UK; 3: Indefinite Leave to Remain in UK ;4: Limited Leave to Remain in UK; 5: No Recourse to Public Funds (NRPF); 6: Other Nationals; 7: Refugee; 8: Unaccompanied Asylum Seeker; 9 EU pre-settled status; 10: EU settled status
treeblank treetree draft  Start date
0 … 1
prsb03-dataelement-13294link
Start date of immigration statusDate and time
treeblank treetree draft  End date
0 … 1
prsb03-dataelement-13295link
End date of immigration statusDate and time
treeblank treetree draft  Comment
0 … 1
prsb03-dataelement-13296link
Relevant comments about the person's immigration statusFree text
treetree draft  Organ and tissue donation
0 … 1
prsb03-dataelement-13847link
Whether the person has given consent for organ and/or tissue donation or opted out of automatic donation where applicable. This is information provided by the national register.Flag: - Yes or No
treetree draft  Overseas visitor status
0 … 1
prsb03-dataelement-10908link
The charging category relating to an overseas visitor.NHS data dictionary :- Overseas visitor charging catergory
folder GP practice
1 … 1 Mandatory
prsb03-dataelement-101link
Details of the person's GP practice.
treetree folder GP practice record entry
0 … *
prsb03-dataelement-10643link
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
treeblank treetree draft  GP name
0 … 1
prsb03-dataelement-10003link
The name of the person's GP. If the person is registered with a GP practice, their usual GP name will be something volunteered by the person or their representative.Free text
treeblank treetree draft  GP practice details
0 … 1
prsb03-dataelement-10002link
Name and address of the person's registered GP practice Registered GP practice details are available from the Person Demographics Service (PDS), or volunteered from the person or their representative. Include details of the practice name and address.Free text
treeblank treetree draft  GP practice identifier
1 … 1 Mandatory
prsb03-dataelement-10001link
The identifier of the registered GP practice. NHS data dictionary : - General medical practice code (patient registration)
folder About me
0 … 1
prsb03-dataelement-466link
About me
treetree folder What is most important to me
0 … 1
prsb03-dataelement-12964link
A description of what is most important to you.
treeblank treetree draft  What is most important to me
0 … 1
prsb03-dataelement-14325link
A description of what is most important to you 
Emergency Information : - Include any essential information that any professional in health and social care should know about the you in any situation, including emergencies.
Other Information : -This could include : - Values, Spirituality/religion, Ethnicity, Culture, Pets, Goals and aspirations, Meaningful activities including leisure activities, visiting places, sport and exercise, listening to music, employment, education, volunteeringFree text
treetree folder People who are important to me
0 … 1
prsb03-dataelement-13009link
Details of who is important to you and why. 
treeblank treetree draft  People who are important to me
0 … 1
prsb03-dataelement-14327link
Details of who is important to you and why. They could be family members, carers, friends, members of staff etc. Include how you want the people important to you to be engaged and involved in your care and support in both emergency and normal situations. Include how you stay connected to the people important to you. Who should not be contacted or consulted about your care and support and why, if you wish to sayFree text 
treetree folder How I communicate and how to communicate with me
0 … 1
prsb03-dataelement-13006link
A description of how you communicate normally. 
treeblank treetree draft  How I communicate and how to communicate with me
0 … 1
prsb03-dataelement-14329link

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

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

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

Free text
treetree folder My wellness
0 … 1
prsb03-dataelement-13005link
A description covering what you are able to do, how you engage with others and how you feel on a typical day through to on a day when you are unwell or really unwell.
treeblank treetree draft  My wellness
0 … 1
prsb03-dataelement-14331link

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

  • Include any causes that might result in you becoming unwell and strategies for avoiding or addressing the causes. For example, not drinking enough water could cause constipation.
  • Include any signs that indicate you might be becoming unwell.
  • On a bad day describe what is different about what you are able to do, how you engage with others and how you feel.
  • Include how your everyday life is affected by any medical conditions e.g. dementia and any symptoms e.g. itchiness, cough, pain and how you manage those conditions.
  • Include past health issues or experiences that need to be considered
  • Include your wellbeing and lifestyle goals and aspirations

    Free text
    treetree folder Please do and please don't
    0 … 1
    prsb03-dataelement-13008link
    A description of things you want someone supporting you to do (or not to do). 
    treeblank treetree draft  Please do and please don't
    0 … 1
    prsb03-dataelement-14333link
    A description of things you want someone supporting you to do (or not to do).
    Things you want someone to do might include (for example): - Talk to me not to my carer, remind me to take my medication, encourage me to wash my hands regularly, explain to me what is happening and why, respond to my communication.
    A description of things you do not want someone supporting you to do might include (for example): - Discussing or asking questions about certain topics, making assumptions about something, providing support when it is not wanted, talking to you in a certain way, undergoing a specific intervention or taking a medication the person does not want.Free text
    treetree folder How and when to support me
    0 … 1
    prsb03-dataelement-13007link
    A description of how and when you want someone caring for you to support you.
    treeblank treetree draft  How and when to support me
    0 … 1
    prsb03-dataelement-14335link

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

    • This could include support needs in an emergency situation (for example taking blood)
    • This could include support you need to maintain important routines or to carry out particular activities, for example: - Personal care routines, Eating and drinking, Bedtime routines, Taking medications, Moving and transitioning
    • This could also include support needed with:- wearing glasses/hearing aids/false teeth etc, making informed choices or understanding dangers and risks, managing your emotions, moods and behaviours, memory or confusion.
    • Include how your support needs change in different environments. Include any triggers that might result in you needing further support and strategies for avoiding or addressing the triggers. Include how you want the support to be provided.

    Free text
    treetree folder Also worth knowing about me
    0 … 1
    prsb03-dataelement-13094link
    A description of what is also worth knowing about you for people caring or supporting you. 
    treeblank treetree draft  Also worth knowing about me
    0 … 1
    prsb03-dataelement-14337link

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

    • This could include a short history of your life (where you have worked, where you lived, important events in your life, important people in your past life).
    • This could include a short profile of your current life:- your work / study, your aspirations, your skills, your networks, things you like e.g. particular foods, places, a football team and things you like to talk about, things you dislike
    • This could also include any care and support preferences that have not been included elsewhere.

    Free text
    treetree draft  Date
    0 … 1
    prsb03-dataelement-10367link
    This is a record of the date that this information was last updated.Date and Time
    treetree draft  Supported to write this by
    0 … 1
    prsb03-dataelement-10368link
    Where relevant, this is a record of name, relationship/role and contact details of the individual who supported the person to write this section e.g. carer, family member, advocate, professional.Free text
    treetree draft  Location to multimedia file
    0 … 1
    prsb03-dataelement-14326link
    The link to the person's multimedia fileLink to URL
    folder Individual requirements
    0 … 1
    prsb03-dataelement-160link
    The individual requirements of the person.
    treetree folder Reasonable adjustment
    0 … 1
    prsb03-dataelement-12991link
    A record of reasonable adjustments that must be provided by the service to comply with the Equality Act 2010.
    treeblank treetree folder Reasonable adjustment record entry
    0 … *
    prsb03-dataelement-13061link
    This is a reasonable adjustment record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items
    treeblank treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-13098link
    The location where the reasonable adjustment was identified.
    treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13357link
    The coded value for location.NHS Data dictionary : - Organisation data service code
    treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13358link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treetree draft  Reasonable adjustment flag
    0 … 1
    prsb03-dataelement-13874link

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

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

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

    SNOMED CT: - 1108111000000107 |Requires reasonable adjustments for health and care access (Equality Act 2010) (finding)|
    treeblank treeblank treetree folder Reasonable adjustment
    0 … 1
    prsb03-dataelement-13017link
    The reasonable adjustment required e.g. requires specific contact method, requires communication professional
    treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13505link
    The coded value for reasonable adjustmentSNOMED CT : - Accessible information standard^999002121000000109 |Accessible information - communication support simple reference set (foundation metadata concept)|^999002151000000104 |Accessible information - requires communication professional simple reference set (foundation metadata concept)|^999002131000000106 |Accessible information - requires specific contact method simple reference set (foundation metadata concept)|^999002141000000102 |Accessible information - requires specific information format simple reference set (foundation metadata concept)|Refsets for other categories in development
    treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13506link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treetree draft  Reasonable adjustment additional detail
    0 … 1
    prsb03-dataelement-13018link
    Further detail about the support required and the consequence of not providing it.Free text
    treeblank treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-13020link
    The date the reasonable adjustment was identified.Date and time
    treeblank treeblank treetree folder Performing professional
    0 … 1
    prsb03-dataelement-13027link
    The professional who confirmed the need for the reasonable adjustment.
    treeblank treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-13028link
    The name of the professional.Free text.
    treeblank treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-13029link
    The role the professional has in relation to the person.FHIR value set : - sdsjobrole
    treeblank treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-13030link
    The grade of the professional.Free text
    treeblank treeblank treeblank treetree draft  Speciality
    0 … 1
    prsb03-dataelement-13031link
    The specialty of the professional.NHS data dictionary - Main specialty code
    treeblank treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-13032link
    Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
    treeblank treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-13033link
    The name of the organisation the professional works for.
    treeblank treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-13034link
    Contact details of the professionalNHS data dictionary - UK phone number
    treeblank treeblank treetree folder Person completing record
    0 … 1
    prsb03-dataelement-13035link
    A record of the details of the person that entered the reasonable adjustment and the date on which it was entered.
    treeblank treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-13036link
    The name of the person completing the record.Free text.
    treeblank treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-13037link
    The organisational role of the person completing record.FHIR value set :- SDSjobrole
    treeblank treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-13038link
    The grade of the person completing the record.Free text.
    treeblank treeblank treeblank treetree draft  Specialty
    0 … 1
    prsb03-dataelement-13039link
    The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
    treeblank treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-13040link
    The organisation the person completing the record works for. NHS data dictionary : - Organisation data service
    treeblank treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-13041link
    Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
    treeblank treeblank treeblank treetree draft  Date completed
    0 … 1
    prsb03-dataelement-13042link
    The date and time the record was completed.Date and time.
    treeblank treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-13043link
    Contact details of the person completing the record.
    NHS data dictionary : - UK telephone number
    treetree folder Impairment
    0 … 1
    prsb03-dataelement-13001link
    A record of any impairments for the person relating to reasonable adjustments.
    treeblank treetree folder Impairment record entry
    0 … *
    prsb03-dataelement-13062link
    This is an impairment record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items
    treeblank treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-13099link
    The location where the impairment was identified.
    treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13429link
    The coded value for location.NHS data dictionary: - Organisation code service
    treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13430link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treetree folder Impairment category
    0 … 1
    prsb03-dataelement-13022link
    The category of the impairment e.g. Autism, Dementia, Physical disability, Sensory disability - such as sight or hearing, Long-term condition
    treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13507link
    The coded value for impairment.SNOMED CT
    treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13508link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treetree draft  Impairment additional detail
    0 … 1
    prsb03-dataelement-13023link

    Description of what the person can do with the impairment, what they want to be able to do and how they should be supported to do it and what the consequences are of not providing the support.
    Where there is a sensory disability include sensory processing difficulties (e.g. affects to balance and movement, oversensitive, under-sensitive).
    Free text
    treeblank treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-13024link
    The date the impairment was identified.Date and time
    treeblank treeblank treetree folder Performing professional
    0 … 1
    prsb03-dataelement-13044link
    The professional who confirmed the impairment.
    treeblank treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-13045link
    The name of the professional.Free text.
    treeblank treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-13046link
    The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
    treeblank treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-13047link
    The grade of the professional.Free text
    treeblank treeblank treeblank treetree draft  Speciality
    0 … 1
    prsb03-dataelement-13048link
    The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
    treeblank treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-13049link
    Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
    treeblank treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-13050link
    The name of the organisation the professional works for.
    treeblank treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-13051link
    Contact details of the professionalNHS data dictionary - UK phone number
    treeblank treeblank treetree folder Person completing record
    0 … 1
    prsb03-dataelement-13052link

    A record of the details of the person that entered the impairment and the date on which it was entered.
    treeblank treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-13053link
    The name of the person completing the record.Free text.
    treeblank treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-13054link
    The organisational role of the person completing record.FHIR value set :- SDSjobrole
    treeblank treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-13055link
    The grade of the person completing the record.Free text.
    treeblank treeblank treeblank treetree draft  Specialty
    0 … 1
    prsb03-dataelement-13056link
    The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
    treeblank treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-13057link
    The organisation the person completing the record works for. NHS data dictionary : - Organisation data service
    treeblank treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-13058link
    Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
    treeblank treeblank treeblank treetree draft  Date completed
    0 … 1
    prsb03-dataelement-13059link
    The date and time the record was completed.Date and time.
    treeblank treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-13060link
    Contact details of the person completing the record.
    NHS data dictionary : - UK telephone number
    treetree folder Cognition
    0 … *
    prsb03-dataelement-10066link
    Details of the persons cognitive impairment.
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-11705link
    The date when the cognitive impairment was identified.Date and time
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-11706link
    The location where the cognitive impairment was identified.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13431link
    The coded value for location.NHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13432link
    Free text field to be used if no code is availableFree text
    treeblank treetree draft  Cognition
    0 … 1
    prsb03-dataelement-13669link
    The cognitive impairment to be considered when communicating with the person, child or their primary carer.Free text
    treeblank treetree folder Performing professional
    0 … 1
    prsb03-dataelement-11470link
    The professional who identified the cognitive impairment.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-11471link
    The name of the professional.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-11472link
    The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-11473link
    The grade of the professional.Free text
    treeblank treeblank treetree draft  Speciality
    0 … 1
    prsb03-dataelement-11474link
    The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-11475link
    Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-11476link
    The name of the organisation the professional works for.
    treeblank treeblank treetree draft  Contact details
    0 … *
    prsb03-dataelement-11477link
    Contact details of the professionalNHS data dictionary - UK phone number
    treeblank treetree folder Person completing record
    0 … 1
    prsb03-dataelement-11478link
    Details of the person completing the record.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-11479link
    The name of the person completing the record.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-11480link
    The organisational role of the person completing record.FHIR value set :- SDSjobrole
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-11481link
    The grade of the person completing the record.Free text.
    treeblank treeblank treetree draft  Specialty
    0 … 1
    prsb03-dataelement-11482link
    The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-11483link
    The organisation the person completing the record works for. NHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-11484link
    Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
    treeblank treeblank treetree draft  Date completed
    0 … 1
    prsb03-dataelement-11485link
    The date and time the record was completed.Date and time.
    treeblank treeblank treetree draft  Contact details
    0 … *
    prsb03-dataelement-11486link
    Contact details of the person completing the record.
    NHS data dictionary : - UK telephone number
    treetree folder Mobility
    0 … *
    prsb03-dataelement-10067link
    Details of the person's mobility needs.
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-11707link
    The date when the mobility needs were identified.Date and time
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-11710link
    The location where the mobility needs were identified.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13433link
    The coded value for location.NHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13434link
    Free text field to be used if no coded text available
    treeblank treetree folder Mobility needs
    0 … 1
    prsb03-dataelement-13670link
    The mobility needs of the person that allows movement between two spaces and achieves participation and a degree of independence.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13671link
    The coded value for mobility needsSNOMED CT: - ^999002551000000108 |Mobility findings simple reference set (foundation metadata concept)|
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13672link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Performing professional
    0 … 1
    prsb03-dataelement-11487link
    The professional who identified the mobility needs.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-11488link
    The name of the professional.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-11489link
    The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-11490link
    The grade of the professional.Free text
    treeblank treeblank treetree draft  Speciality
    0 … 1
    prsb03-dataelement-11491link
    The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-11492link
    Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-11493link
    The name of the organisation the professional works for.
    treeblank treeblank treetree draft  Contact details
    0 … *
    prsb03-dataelement-11494link
    Contact details of the professionalNHS data dictionary - UK phone number
    treeblank treetree folder Person completing record
    0 … 1
    prsb03-dataelement-11495link
    Details of the person completing the record.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-11496link
    The name of the person completing the record.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-11497link
    The organisational role of the person completing record.FHIR value set :- SDSjobrole
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-11498link
    The grade of the person completing the record.Free text.
    treeblank treeblank treetree draft  Specialty
    0 … 1
    prsb03-dataelement-11499link
    The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-11500link
    The organisation the person completing the record works for. NHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-11501link
    Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
    treeblank treeblank treetree draft  Date completed
    0 … 1
    prsb03-dataelement-11502link
    The date and time the record was completed.Date and time.
    treeblank treeblank treetree draft  Contact details
    0 … *
    prsb03-dataelement-11503link
    Contact details of the person completing the record.
    NHS data dictionary : - UK telephone number
    treetree folder Other individual requirements
    0 … *
    prsb03-dataelement-10835link
    Details of any other individual requirements the person may have
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-11711link
    The date when the other individual requirements were identified.Date and time
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-11712link
    The location where the other individual requirements were identified.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13435link
    The coded value for location.NHS data dictionary : - Organisation service code
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13436link
    Free text field to be used if no coded text available
    treeblank treetree draft  Other individual requirement
    0 … 1
    prsb03-dataelement-13673link
    Other individual requirements that a person may have.Free text
    treeblank treetree folder Performing professional
    0 … 1
    prsb03-dataelement-11504link
    The professional who identified the other individual requirements.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-11505link
    The name of the professional.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-11506link
    The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-11507link
    The grade of the professional.Free text
    treeblank treeblank treetree draft  Speciality
    0 … 1
    prsb03-dataelement-11508link
    The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-11509link
    Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-11510link
    The name of the organisation the professional works for.
    treeblank treeblank treetree draft  Contact details
    0 … *
    prsb03-dataelement-11511link
    Contact details of the professionalNHS data dictionary - UK phone number
    treeblank treetree folder Person completing record
    0 … 1
    prsb03-dataelement-11512link
    Details of the person completing the record.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-11513link
    The name of the person completing the record.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-11514link
    The organisational role of the person completing record.FHIR value set :- SDSjobrole
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-11515link
    The grade of the person completing the record.Free text.
    treeblank treeblank treetree draft  Specialty
    0 … 1
    prsb03-dataelement-11516link
    The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-11517link
    The organisation the person completing the record works for. NHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-11518link
    Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
    treeblank treeblank treetree draft  Date completed
    0 … 1
    prsb03-dataelement-11519link
    The date and time the record was completed.Date and time.
    treeblank treeblank treetree draft  Contact details
    0 … *
    prsb03-dataelement-11520link
    Contact details of the person completing the record.
    NHS data dictionary : - UK telephone number
    folder Alerts
    0 … 1
    prsb03-dataelement-10741link
    Details of alerts.
    treetree folder Alerts record entry
    0 … *
    prsb03-dataelement-10916link
    This is an alerts record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items
    treeblank treetree draft  Alert
    0 … 1
    prsb03-dataelement-10742link
    Any significant information meriting a specific and highly visible warning to any user (e.g. metallic implant, potential dangerous pet).Free text
    treeblank treetree folder Person completing record
    0 … 1
    prsb03-dataelement-12399link
    Details of the person completing the record.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-12400link
    The name of the person completing the record.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-12401link
    The organisational role of the person completing record.FHIR value set :- SDSjobrole
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-12402link
    The grade of the person completing the record.Free text.
    treeblank treeblank treetree draft  Specialty
    0 … 1
    prsb03-dataelement-12403link
    The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-12404link
    The organisation the person completing the record works for. NHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-12405link
    Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
    treeblank treeblank treetree draft  Date completed
    0 … 1
    prsb03-dataelement-12406link
    The date and time the record was completed.Date and time.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-12407link
    Contact details of the person completing the record.
    NHS data dictionary : - UK telephone number
    folder Legal information
    0 … 1
    prsb03-dataelement-520link
    The legal information relating to the person.
    treetree folder Consent for information sharing
    0 … 1
    prsb03-dataelement-10421link
    Details of the person's consent for information sharing
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-11713link
    The date when the consent was givenDate and time
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-11714link
    The location where the consent was taken.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13451link
    The coded value for location.NHS data dictionary : - Organisation data service code
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13452link
    Free text field to be used if no code is availableFree text
    treeblank treetree draft  Consent for information sharing
    0 … 1
    prsb03-dataelement-13575link
    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.Free text
    treeblank treetree draft  Reason for consent not given
    0 … 1
    prsb03-dataelement-13778link
    Reason not given for consentFree text
    treeblank treetree folder Performing professional
    0 … 1
    prsb03-dataelement-11715link
    The professional who took the consent for information sharing
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-11716link
    The name of the professional.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-11717link
    The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-11718link
    The grade of the professional.Free text
    treeblank treeblank treetree draft  Speciality
    0 … 1
    prsb03-dataelement-11719link
    The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-11720link
    Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-11721link
    The name of the organisation the professional works for.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-11722link
    Contact details of the professionalNHS data dictionary - UK phone number
    treeblank treetree folder Person completing record
    0 … 1
    prsb03-dataelement-11723link
    Details of the person completing the record.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-11724link
    The name of the person completing the record.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-11725link
    The organisational role of the person completing record.FHIR value set :- SDSjobrole
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-11726link
    The grade of the person completing the record.Free text.
    treeblank treeblank treetree draft  Specialty
    0 … 1
    prsb03-dataelement-11727link
    The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-11728link
    The organisation the person completing the record works for. NHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-11729link
    Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
    treeblank treeblank treetree draft  Date completed
    0 … 1
    prsb03-dataelement-11730link
    The date and time the record was completed.Date and time.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-11731link
    Contact details of the person completing the record.
    NHS data dictionary : - UK telephone number
    treetree folder Consent relating to child
    0 … *
    prsb03-dataelement-10422link
    Details of the person's consent relating to child
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-11732link
    The date when the person with responsibility for the child was identified.Date and time
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-11733link
    The location where the person with responsibility for the child was identified.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13674link
    The coded value for locationNHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13675link
    Free text field to be used if no coded text available
    treeblank treetree draft  Consent relating to child
    0 … 1
    prsb03-dataelement-13576link
    The person with parental responsibility or appointed guardian where a child lacks competency. Consideration of age and competency, applying Gillick competency or Fraser guidelines.Free text
    treeblank treetree folder Performing professional
    0 … 1
    prsb03-dataelement-11734link
    The professional who identified the person responsible for the child.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-11735link
    The name of the professional.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-11736link
    The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-11737link
    The grade of the professional.Free text
    treeblank treeblank treetree draft  Speciality
    0 … 1
    prsb03-dataelement-11738link
    The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-11739link
    Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-11740link
    The name of the organisation the professional works for.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-11741link
    Contact details of the professionalNHS data dictionary - UK phone number
    treeblank treetree folder Person completing record
    0 … 1
    prsb03-dataelement-11742link
    Details of the person completing the record.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-11743link
    The name of the person completing the record.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-11744link
    The organisational role of the person completing record.FHIR value set :- SDSjobrole
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-11745link
    The grade of the person completing the record.Free text.
    treeblank treeblank treetree draft  Specialty
    0 … 1
    prsb03-dataelement-11746link
    The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-11747link
    The organisation the person completing the record works for. NHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-11748link
    Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
    treeblank treeblank treetree draft  Date completed
    0 … 1
    prsb03-dataelement-11749link
    The date and time the record was completed.Date and time.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-11750link
    Contact details of the person completing the record.
    NHS data dictionary : - UK telephone number
    treetree folder Mental capacity assessment
    0 … *
    prsb03-dataelement-10424link
    Details of the persons mental capacity assessment
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-11688link
    The date when the mental capacity assessment was made.Date and time
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-11689link
    The location where the mental capacity assessment was made.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13449link
    The coded value for location NHS data dictionary : - Organisation code
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13450link
    Free text field to be used if no code is availableFree text
    treeblank treetree draft  Mental capacity assessment
    0 … 1
    prsb03-dataelement-13724link
    Whether an assessment of the mental capacity of the (adult) person has been undertaken, if so, what capacity the decision relates to and the outcome of the assessment. Also record best interests decision if person lacks capacity.Free text
    treeblank treetree draft  Location of document
    0 … 1
    prsb03-dataelement-13779link
    The location of the mental capacity assessment information.Free text or URL
    treeblank treetree folder Performing professional
    0 … 1
    prsb03-dataelement-11281link
    The professional who made the mental capacity assessment.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-11282link
    The name of the professional.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-11283link
    The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-11288link
    The grade of the professional.Free text
    treeblank treeblank treetree draft  Speciality
    0 … 1
    prsb03-dataelement-11284link
    The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-11285link
    Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-11286link
    The name of the organisation the professional works for.
    treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13521link
    The coded value for locationNHS data dictionary: - Organisation data service
    treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13522link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-11287link
    Contact details of the professionalNHS data dictionary - UK phone number
    treeblank treetree folder Person completing record
    0 … 1
    prsb03-dataelement-11289link
    Details of the person completing the record.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-11290link
    The name of the person completing the record.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-11291link
    The organisational role of the person completing record.FHIR value set :- SDSjobrole
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-11292link
    The grade of the person completing the record.Free text.
    treeblank treeblank treetree draft  Specialty
    0 … 1
    prsb03-dataelement-11293link
    The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-11294link
    The organisation the person completing the record works for. NHS data dictionary : - Organisation data service
    treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13523link
    The coded value for locationNHS data dictionary : - Organisation data service
    treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13524link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-11295link
    Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
    treeblank treeblank treetree draft  Date completed
    0 … 1
    prsb03-dataelement-11296link
    The date and time the record was completed.Date and time.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-11297link
    Contact details of the person completing the record.
    NHS data dictionary : - UK telephone number
    treetree folder Lasting power of attorney for health and welfare or court-appointed deputy (or equivalent)
    0 … *
    prsb03-dataelement-10425link
    Details of the person's LPA record or equivalent
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-13630link
    The date the LPA was recordedDate and time
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-13631link
    The location where the LPA was given
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13632link
    The coded value for locationNHS data dictionary : - Organisation code
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13633link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Lasting power of attorney for health and welfare or court appointed deputy (or equivalent)
    0 … 1
    prsb03-dataelement-13634link
    Record of one or more people who have been given power (LPA) by the person when they had capacity to make decisions about their health and welfare should they lose capacity to make those decisions. To be valid, an LPA must have been registered with the Court of Protection. If life-sustaining treatment is being considered the LPA document must state specifically that the attorney has been given power to consent to or refuse life-sustaining treatment. Details of any person (deputy) appointed by the court to make decisions about the person’s health and welfare. A deputy does not have the power to refuse life-sustaining treatment.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13636link
    The coded value for the LPASNOMED CT: - ^999001951000000107 |Personal welfare lasting power of attorney findings simple reference set (foundation metadata concept)|
    treeblank treeblank treetree draft  Location of document
    0 … 1
    prsb03-dataelement-13776link
    The location of the LPA informationFree text or URL
    treeblank treeblank treetree draft  Name of LPA
    0 … 1
    prsb03-dataelement-13635link
    The names of any appointed people or deputiesFree text
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-13637link
    The contact details of the LPANHS data dictionary:- UK telephone number
    treeblank treetree folder Performing professional
    0 … 1
    prsb03-dataelement-13638link
    The professional who took the details of the LPA or equivalent
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-13639link
    The name of the professional.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-13640link
    The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-13641link
    The grade of the professional.Free text
    treeblank treeblank treetree draft  Speciality
    0 … 1
    prsb03-dataelement-13642link
    The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-13643link
    Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-13644link
    The name of the organisation the professional works for.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-13645link
    Contact details of the professionalNHS data dictionary - UK phone number
    treeblank treetree folder Person completing record
    0 … 1
    prsb03-dataelement-13646link
    Details of the person who took the LPA.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-13647link
    The name of the person completing the record.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-13648link
    The organisational role of the person completing record.FHIR value set :- SDSjobrole
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-13649link
    The grade of the person completing the record.Free text.
    treeblank treeblank treetree draft  Specialty
    0 … 1
    prsb03-dataelement-13650link
    The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-13651link
    The organisation the person completing the record works for. NHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-13652link
    Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
    treeblank treeblank treetree draft  Date completed
    0 … 1
    prsb03-dataelement-13653link
    The date and time the record was completed.Date and time.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-13654link
    Contact details of the person completing the record.
    NHS data dictionary : - UK telephone number
    treetree folder Deprivation of Liberty Safeguards or equivalent
    0 … *
    prsb03-dataelement-10426link
    Details of the person's Deprivation of Liberty Safeguards (DoLS) or equivalent
    treeblank treetree draft  Application date
    0 … 1
    prsb03-dataelement-13068link
    The date the application was madeDate and time
    treeblank treetree draft  Application status
    0 … 1
    prsb03-dataelement-13069link
    The status of the DOLs application.Free text : - Requested or authorised
    treeblank treetree draft  Deprivation of liberty safeguards or equivalent
    0 … 1
    prsb03-dataelement-13626link
    Record of Deprivation of Liberty Safeguards (DoLS) or equivalent, including the reason for this.Free text
    treeblank treetree draft  Start date of authorisation
    0 … 1
    prsb03-dataelement-13071link
    The date the DOLs was authorised.Data and time
    treeblank treetree draft  Planned or actual end date of authorisation
    0 … 1
    prsb03-dataelement-13072link
    The planned or actual end date of authorisation.Date and time
    treeblank treetree folder Performing professional
    0 … 1
    prsb03-dataelement-13073link
    The professional who applied for the DOLs.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-13074link
    The name of the professional.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-13075link
    The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-13076link
    The grade of the professional.Free text
    treeblank treeblank treetree draft  Speciality
    0 … 1
    prsb03-dataelement-13077link
    The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-13078link
    Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-13079link
    The name of the organisation the professional works for.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-13080link
    Contact details of the professionalNHS data dictionary - UK phone number
    treetree folder Mental health act or equivalent status
    0 … *
    prsb03-dataelement-10427link
    Details of the persons mental health act record
    treeblank treetree draft  Section start date
    0 … 1
    prsb03-dataelement-10920link
    The date the person was detained.Date and time
    treeblank treetree draft  Section end date
    0 … 1
    prsb03-dataelement-10921link
    The date the person was no longer detained.Date and time
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-11692link
    The location where the decision to detain the person was made under the mental health act.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13453link
    The coded value for locationNHS data dictionary : - Organisation code
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13454link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Mental health act or equivalent status
    0 … 1
    prsb03-dataelement-13627link
    Record where a person diagnosed with a mental disorder is formally detained under the Mental health act or equivalent, including the section number. If person subject to Community Treatment Order or Conditional Discharge (or equivalent) record here.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13628link
    The coded value for mental health actNHS data dictionary: - Mental health act legal status classification code
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13629link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treetree draft  Supporting information
    0 … 1
    prsb03-dataelement-13755link
    If person subject to Community Treatment Order or Conditional Discharge (or equivalent) record here.NHS data dictionary : - Community treatment order
    treeblank treetree folder Performing professional
    0 … 1
    prsb03-dataelement-11315link
    The professional who made the decision to detain the person under the mental health act.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-11316link
    The name of the professional.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-11317link
    The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-11318link
    The grade of the professional.Free text
    treeblank treeblank treetree draft  Speciality
    0 … 1
    prsb03-dataelement-11319link
    The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-11320link
    Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-11321link
    The name of the organisation the professional works for.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-11322link
    Contact details of the professionalNHS data dictionary - UK phone number
    treeblank treetree folder Person completing record
    0 … 1
    prsb03-dataelement-11323link
    Details of the person completing the record.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-11324link
    The name of the person completing the record.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-11325link
    The organisational role of the person completing record.FHIR value set :- SDSjobrole
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-11326link
    The grade of the person completing the record.Free text.
    treeblank treeblank treetree draft  Specialty
    0 … 1
    prsb03-dataelement-11327link
    The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-11328link
    The organisation the person completing the record works for. NHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-11329link
    Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
    treeblank treeblank treetree draft  Date completed
    0 … 1
    prsb03-dataelement-11330link
    The date and time the record was completed.Date and time.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-11331link
    Contact details of the person completing the record.
    NHS data dictionary : - UK telephone number
    treetree folder Advance decision to refuse treatment (ADRT)
    0 … 1
    prsb03-dataelement-10428link
    Details of the person's ADRT status.
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-13479link
    The date the ADRT was recorded.Date
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-13480link
    The location where the ADRT was recorded.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13481link
    The coded value of locationNHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13482link
    Free text field to be used if no coded text available
    treeblank treetree folder Advance decision to refuse treatment
    0 … 1
    prsb03-dataelement-13502link
    A record of an advance decision to refuse one or more specific types of future treatment, made by a person who had capacity at the time of recording the decision. The decision only applies when the person no longer has the capacity to consent to or refuse the specific treatment being considered. An ADRT must be in writing, signed and witnessed. If the ADRT is refusing life-sustaining treatment it must state specifically that the treatment is refused even if the person’s life is at risk.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13503link
    The coded value for advance decision to refuse treatment.SNOMED CT:- ^999002181000000105 |Advance decision to refuse treatment preference findings simple reference set (foundation metadata concept)|
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13504link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Performing professional
    0 … 1
    prsb03-dataelement-13484link
    The professional who recorded the ADRT
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-13485link
    The name of the professional.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-13486link
    The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-13487link
    The grade of the professional.Free text
    treeblank treeblank treetree draft  Speciality
    0 … 1
    prsb03-dataelement-13488link
    The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-13489link
    Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-13490link
    The name of the organisation the professional works for.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-13491link
    Contact details of the professionalNHS data dictionary - UK phone number
    treeblank treetree folder Person completing record
    0 … 1
    prsb03-dataelement-13492link
    Details of the person who recorded the ADRT.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-13493link
    The name of the person completing the record.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-13494link
    The organisational role of the person completing record.FHIR value set :- SDSjobrole
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-13495link
    The grade of the person completing the record.Free text.
    treeblank treeblank treetree draft  Specialty
    0 … 1
    prsb03-dataelement-13496link
    The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-13497link
    The organisation the person completing the record works for. NHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-13498link
    Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
    treeblank treeblank treetree draft  Date completed
    0 … 1
    prsb03-dataelement-13499link
    The date and time the record was completed.Date and time.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-13500link
    Contact details of the person completing the record.
    NHS data dictionary : - UK telephone number
    folder Safeguarding
    0 … 1
    prsb03-dataelement-271link
    The safeguarding details of the person.
    treetree folder Safeguarding concerns
    0 … *
    prsb03-dataelement-10821link
    Details of safeguarding concerns
    treeblank treetree draft  Safeguarding indicator
    0 … 1
    prsb03-dataelement-13428link
    Indicates whether or not the hospital considers that there are safeguarding issues associated with the patient.Flag: No =N: Yes = Y
    treeblank treetree draft  Safeguarding concerns date
    0 … 1
    prsb03-dataelement-10172link
    The date the safeguarding concerns were identified.Date and time
    treeblank treetree draft  Safeguarding concerns end date
    0 … 1
    prsb03-dataelement-10766link
    The date safeguarding concerns ended.Date and time
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-10173link
    The location where the safeguarding concerns were identified.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13437link
    The coded value of locationNHS data dictionary : - Organisation code
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13438link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Safeguarding concerns
    0 … 1
    prsb03-dataelement-10171link
    Identified safeguarding concerns.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13756link
    The coded value for safeguarding concernsSNOMED CT : - ^999002381000000108 | Safeguarding issues simple reference set (foundation metadata concept) |
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13757link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Performing professional
    0 … 1
    prsb03-dataelement-11358link
    The professional who identified the safeguarding concerns.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-11359link
    The name of the professional.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-11360link
    The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-11361link
    The grade of the professional.Free text
    treeblank treeblank treetree draft  Speciality
    0 … 1
    prsb03-dataelement-11362link
    The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-11363link
    Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-11364link
    The name of the organisation the professional works for.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-11365link
    Contact details of the professionalNHS data dictionary - UK phone number
    treeblank treetree folder Person completing record
    0 … 1
    prsb03-dataelement-11366link
    Details of the person completing the record.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-11367link
    The name of the person completing the record.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-11368link
    The organisational role of the person completing record.FHIR value set :- SDSjobrole
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-11369link
    The grade of the person completing the record.Free text.
    treeblank treeblank treetree draft  Specialty
    0 … 1
    prsb03-dataelement-11370link
    The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-11371link
    The organisation the person completing the record works for. NHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-11372link
    Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
    treeblank treeblank treetree draft  Date completed
    0 … 1
    prsb03-dataelement-11373link
    The date and time the record was completed.Date and time.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-11374link
    Contact details of the person completing the record.
    NHS data dictionary : - UK telephone number
    treeblank treetree draft  Comment
    0 … 1
    prsb03-dataelement-10175link
    Further details on safeguarding concerns.Free text
    treetree folder Looked after child
    0 … *
    prsb03-dataelement-10797link
    Details of the looked after child
    treeblank treetree draft  Looked after child start date
    0 … 1
    prsb03-dataelement-10746link
    The date the child became a looked after child.Date and time
    treeblank treetree draft  Looked after child end date
    0 … 1
    prsb03-dataelement-10761link
    The date the child ceased to be a looked after child.Date and time
    treeblank treetree folder Local authority
    0 … 1
    prsb03-dataelement-10799link
    The named local authority.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13614link
    The coded value for local authorityNHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13615link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Person completing record
    0 … 1
    prsb03-dataelement-11375link
    Details of the person completing the record.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-11376link
    The name of the person completing the record.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-11377link
    The organisational role of the person completing record.FHIR value set :- SDSjobrole
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-11378link
    The grade of the person completing the record.Free text.
    treeblank treeblank treetree draft  Specialty
    0 … 1
    prsb03-dataelement-11379link
    The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-11380link
    The organisation the person completing the record works for. NHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-11381link
    Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
    treeblank treeblank treetree draft  Date completed
    0 … 1
    prsb03-dataelement-11382link
    The date and time the record was completed.Date and time.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-11383link
    Contact details of the person completing the record.
    NHS data dictionary : - UK telephone number
    treetree folder Child protection plan
    0 … *
    prsb03-dataelement-10798link
    Details of the child protection plan
    treeblank treetree draft  Child protection plan start date
    0 … 1
    prsb03-dataelement-10747link
    The start date of the child protection planDate and time
    treeblank treetree draft  Child protection plan end date
    0 … 1
    prsb03-dataelement-10762link
    The end date of the child protection planDate and time
    treeblank treetree folder Local authority
    0 … 1
    prsb03-dataelement-10748link
    The named local authority.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13616link
    The coded value for a local authorityNHS data dictionary : - organisation data service
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13617link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Person completing record
    0 … 1
    prsb03-dataelement-11384link
    Details of the person completing the record.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-11385link
    The name of the person completing the record.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-11386link
    The organisational role of the person completing record.FHIR value set :- SDSjobrole
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-11387link
    The grade of the person completing the record.Free text.
    treeblank treeblank treetree draft  Specialty
    0 … 1
    prsb03-dataelement-11388link
    The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-11389link
    The organisation the person completing the record works for. NHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-11390link
    Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
    treeblank treeblank treetree draft  Date completed
    0 … 1
    prsb03-dataelement-11391link
    The date and time the record was completed.Date and time.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-11392link
    Contact details of the person completing the record.
    NHS data dictionary : - UK telephone number
    treetree folder Unborn child protection plan
    0 … *
    prsb03-dataelement-10923link
    Details of the unborn child protection plan.
    treeblank treetree draft  Unborn child protection plan start date
    0 … 1
    prsb03-dataelement-10924link
    Start date of the unborn child protection plan.Date and time
    treeblank treetree draft  Unborn child protection plan end date
    0 … 1
    prsb03-dataelement-10925link
    End date of the unborn child protection plan.Date and time
    treeblank treetree folder Local authority
    0 … 1
    prsb03-dataelement-10926link
    The named local authority.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13618link
    The coded value for local authorityNHS data dictionary: - Organisation data service
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13619link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Person completing record
    0 … 1
    prsb03-dataelement-11393link
    Details of the person completing the record.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-11394link
    The name of the person completing the record.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-11395link
    The organisational role of the person completing record.FHIR value set :- SDSjobrole
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-11396link
    The grade of the person completing the record.Free text.
    treeblank treeblank treetree draft  Specialty
    0 … 1
    prsb03-dataelement-11397link
    The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-11398link
    The organisation the person completing the record works for. NHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-11399link
    Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
    treeblank treeblank treetree draft  Date completed
    0 … 1
    prsb03-dataelement-11400link
    The date and time the record was completed.Date and time.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-11401link
    Contact details of the person completing the record.
    NHS data dictionary : - UK telephone number
    folder Professional contacts
    0 … 1
    prsb03-dataelement-452link
    The details of the person’s professional contacts.
    treetree folder Professional contacts record entry
    0 … *
    prsb03-dataelement-10767link
    This is a professional contacts record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
    treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-10352link
    The name of the professional with responsibility for the care of the person.Free text
    treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-10353link
    The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker, key worker, care home manager, care coordinator, LA hospital liaison person, care home contact, hospital clinician, Independent Mental Capacity Advocate (IMCA) etcFHIR value set : - SDSjobrole
    treeblank treetree draft  Key worker
    0 … 1
    prsb03-dataelement-12973link
    A flag that identifies the personal contact is the key worker assigned to the person.Flag : - Yes or No
    treeblank treetree draft  Speciality
    0 … 1
    prsb03-dataelement-10354link
    The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary : - Activity treatment function code
    treeblank treetree draft  Team
    0 … 1
    prsb03-dataelement-10355link
    The name of the team.Free text
    treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-10356link
    The name of the organisation.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13564link
    The coded value for locationNHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13565link
    Free text field to be used if no code is availableFree text
    treeblank treetree draft  Contact details
    0 … *
    prsb03-dataelement-10357link
    Contact details of the professional (e.g. telephone number, email address etc.).Free text
    treeblank treetree draft  Start date
    0 … 1
    prsb03-dataelement-10358link
    The start date of the professional relationship with the person.Date and time
    treeblank treetree draft  End date
    0 … 1
    prsb03-dataelement-10359link
    The end date of the professional relationship with the person.Date and time
    folder Personal contacts
    0 … 1
    prsb03-dataelement-445link
    The details of the individual's personal contacts.
    treetree folder Personal contacts record entry
    0 … *
    prsb03-dataelement-10768link
    This is personal contacts record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
    treeblank treetree draft  Name
    1 … 1 Mandatory
    prsb03-dataelement-10345link
    The name of the personal contact.Free text
    treeblank treetree draft  Relationship
    0 … 1
    prsb03-dataelement-10346link
    The relationship the personal contact has to the person, e.g. father, grandmother, family friend etc.FHIR value set : - Related person
    treeblank treetree draft  Relationship type
    0 … 1
    prsb03-dataelement-12968link
    Additional roles the person performs on behalf of the other (e.g. Carer, Next of Kin, Emergency Contact, Dependent, etc.)Free text
    treeblank treetree draft  Contact details
    0 … *
    prsb03-dataelement-10350link
    Contact details of the personal contact (e.g. telephone number, email address etc.)Free Text
    treeblank treetree draft  Comments
    0 … 1
    prsb03-dataelement-10937link
    Notes on the significance of the personal contact to the person.Free text
    folder Participation in research
    0 … 1
    prsb03-dataelement-168link
    Participation in research
    treetree folder Participation in research record entry
    0 … *
    prsb03-dataelement-10646link
    This is a Participation in research record entry. There may be 0 to many record entry/entries under a section. Each record entry is made up of a number of elements or data items.
    treeblank treetree draft  Name of research study
    0 … 1
    prsb03-dataelement-10068link
    Name and details of the research study/trial and/or drug/interventionFree text or URL
    treeblank treetree draft  Identification code
    0 … 1
    prsb03-dataelement-10739link
    Identification code of research studyNHS data dictionary :- Clinical trial identifier
    treeblank treetree folder Person completing record
    0 … 1
    prsb03-dataelement-12201link
    Details of the person completing the record.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-12202link
    The name of the person completing the record.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-12203link
    The organisational role of the person completing record.FHIR value set :- SDSjobrole
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-12204link
    The grade of the person completing the record.Free text.
    treeblank treeblank treetree draft  Specialty
    0 … 1
    prsb03-dataelement-12205link
    The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-12206link
    The organisation the person completing the record works for. NHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-12207link
    Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
    treeblank treeblank treetree draft  Date completed
    0 … 1
    prsb03-dataelement-12208link
    The date and time the record was completed.Date and time.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-12209link
    Contact details of the person completing the record.
    NHS data dictionary : - UK telephone number
    folder Referral details
    0 … 1
    prsb03-dataelement-105link
    The details of the referral.
    treetree folder Referral details record entry
    0 … *
    prsb03-dataelement-10917link
    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.
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-10006link
    The date of referralDate and time
    treeblank treetree folder Referrer details
    0 … 1
    prsb03-dataelement-10005link
    The details of the referrer that is making the referral or the transfer.

    This could be the person, GP surgery, department, specialty, sub-specialty, educational institution, mental health team, care home etc.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-10971link
    The name of the referrer.Free text
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-10972link
    Role of the referrer.FHIR value set : - sdsjobrole
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-10973link
    The grade of the referrer.Free text
    treeblank treeblank treetree draft  Team
    0 … 1
    prsb03-dataelement-12409link
    The team or department of the referrer.Free text
    treeblank treeblank treetree draft  Specialty
    0 … 1
    prsb03-dataelement-12410link
    The specialty of the referrer.NHS data dictionary - Activity treatment function code
    treeblank treeblank treetree folder Service
    0 … 1
    prsb03-dataelement-12411link
    The service of the referrer.
    treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13397link
    The coded value for serviceSNOMED CT: - 1127531000000102 |Services simple reference set (foundation metadata concept)|
    treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13398link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-10974link
    The organisation of the referrer.
    treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13399link
    The coded value for organisation codeNHS data dictionary : - Organisation data service
    treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13400link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-10975link
    The contact details of the referrer.Free text
    treeblank treetree draft  Referral method
    0 … 1
    prsb03-dataelement-10007link
    The method in which a referral is sent and received. This may be a letter, email, transcript of a telephone conversation, Choose and Book, in person (self-referral) etc.Allow National Codes only Fax Phone Secure Messaging Secure Email Letter NHS E-Referral Service Self referral
    treeblank treetree folder Reason for referral
    0 … 1
    prsb03-dataelement-10011link
    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.Free text
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13455link
    The coded value for reason for referralSNOMED CT :- ^1127581000000103 |Health issues simple reference set|
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13456link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Clinical urgency of referral
    0 … 1
    prsb03-dataelement-10010link
    The details of the clinical urgency of referral
    treeblank treeblank treetree draft  Urgency
    0 … 1
    prsb03-dataelement-13835link
    This is the priority of a request for servicesNHS data dictionary : - PRIORITY TYPE
    treeblank treeblank treetree draft  Reason for urgency of referral
    0 … 1
    prsb03-dataelement-10976link
    The reason for urgency of referral if not routine.Free text
    treeblank treetree folder Referral to
    0 … 1
    prsb03-dataelement-10008link
    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.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-10977link
    Name of person the referral is to be sent to.Free text
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-10978link
    Role of person where the referral is to be sent to.FHIR value set : - sdsjobrole
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-10979link
    The grade of the person where the referral is sent to.Free text
    treeblank treeblank treetree draft  Team
    0 … 1
    prsb03-dataelement-10982link
    The team or department of the person where the referral is being sent toFree text.
    treeblank treeblank treetree draft  Specialty
    0 … 1
    prsb03-dataelement-10983link
    The specialty the referral is being sent to e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
    treeblank treeblank treetree folder Service
    0 … 1
    prsb03-dataelement-12412link
    The service of where the referral is sent to.
    treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13509link
    The coded value for serviceSNOMED CT: - 1127531000000102 |Services simple reference set (foundation metadata concept)|
    treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13510link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-10980link
    The organisation of where the referral is to be sent.
    treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13511link
    The coded value for organisationNHS data dictionary :- Organisation data service
    treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13512link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-10981link
    The contact details of where the referral is to be sent.Free text.
    treeblank treetree draft  Referral criteria
    0 … 1
    prsb03-dataelement-10014link
    Records whether specific criteria required for referral, to a particular service, have been met (may be nationally or locally determined). This field is used to outline which criteria have been met where a service has indicated specific criteria and to explain the rationale for referral where criteria have not been met.Free text
    treeblank treetree draft  Return response to
    0 … 1
    prsb03-dataelement-10015link
    Name of professional to be communicated with, if not the referrerFree text.
    folder Contacts with professionals
    0 … 1
    prsb03-dataelement-169link
    The details of the person’s contact with a professional.
    treetree folder Contacts with professionals record entry
    0 … *
    prsb03-dataelement-10718link
    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.
    treeblank treetree draft  Date of contact
    0 … 1
    prsb03-dataelement-10069link
    Date and time of the contact.Date and time.
    treeblank treetree folder Location of contact
    0 … 1
    prsb03-dataelement-10075link
    The location where the contact took place.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13513link
    The coded value for locationNHS data dictionary : - Organisation service code
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13514link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Seen by
    0 … *
    prsb03-dataelement-10077link
    The professional that saw the person.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-13515link
    The name of the professional that saw the personFree text
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-13758link
    The role of the person providing the service.FHIR values set : - sdsjobrole
    treeblank treetree folder Responsible professional
    0 … 1
    prsb03-dataelement-10072link
    The name and role of the professional that had overall responsibility for the person e.g. consultant, nurse consultant, midwife, allied health professional (may not have actually seen the person).
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-10988link
    The name of the responsible professional.Free text
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-10989link
    The role of the responsible professionalFHIR value set : - sdsjobrole
    treeblank treetree draft  Location type
    0 … 1
    prsb03-dataelement-10076link
    The type of location where the contact took place e.g. person's homeNHS data dictionary - Activity location type code
    treeblank treetree draft  Contact type
    0 … 1
    prsb03-dataelement-10070link
    Type of contact e.g. GP consultation, outpatient attendanceFree text
    treeblank treetree draft  Consultation method
    0 … 1
    prsb03-dataelement-10071link
    Consultation method used e.g. face to face, telephoneNHS data dictionary - Consultation medium
    treeblank treetree draft  Specialty
    0 … 1
    prsb03-dataelement-10073link
    The specialty e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
    treeblank treetree draft  Service
    0 … 1
    prsb03-dataelement-10074link
    The service that was provided.SNOMED CT :- 1127531000000102 |Services simple reference set (foundation metadata concept)|
    treeblank treetree folder Professionals present
    0 … *
    prsb03-dataelement-10078link
    The name, role of the additional individuals or team members including consultant(s), nurse consultant(s), allied health professional(s), social worker(s)
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-10990link
    The name of the professional presentFree text
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-10991link
    The role of the professional present.FHIR value set : - sdsjobrole
    treeblank treetree draft  Outcome of contact
    0 … 1
    prsb03-dataelement-10080link
    This records the outcome of the contact. NHS data dictionary :- Attended or did not attend code
    folder Admission details
    0 … 1
    prsb03-dataelement-181link
    Admission details
    treetree folder Admission details record entry
    0 … *
    prsb03-dataelement-10918link
    This is the admission details record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
    treeblank treetree draft  Date of admission
    0 … 1
    prsb03-dataelement-10085link
    Date and time the person was admitted to hospital.Date and time
    treeblank treetree folder Admitted to
    0 … 1
    prsb03-dataelement-10090link
    The hospital the person was admitted to.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13380link
    The coded value for admission toNHS data dictionary : - Organisations code of provider
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13381link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Responsible care professional
    0 … 1
    prsb03-dataelement-10087link
    The care professional who has overall responsibility for the person (may not actually see the person)
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-10992link
    The name of the responsible care professional.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-10993link
    The role of the responsible consultant.FHIR value set: - sdsjobrole
    treeblank treetree folder Reason for admission
    0 … 1
    prsb03-dataelement-10081link
    The health problems and issues experienced by the person that prompted the decision to admit to hospital e.g. chest pain, mental health crisis, blackout, fall, a specific procedure, intervention, investigation or treatment, non compliance with treatment.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13382link
    The coded value for reason for admissionSNOMED CT: - ^1127581000000103 |Health issues simple reference set|
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13384link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Admission method
    0 … 1
    prsb03-dataelement-10082link
    How the person was admitted to hospital e.g. elective, emergency, maternity, transfer etc.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13385link
    The coded value for admission methodNHS data dictionary : - Admission method
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13387link
    Free text field to be used if no code is availableFree text
    treeblank treetree draft  Legal status on admission
    0 … 1
    prsb03-dataelement-10083link
    Whether the person was admitted as informal or formal/detained.NHS data dictionary : - Mental health act legal status classification code
    treeblank treetree folder Source of admission
    0 … 1
    prsb03-dataelement-10084link
    Where the person was immediately prior to admission, e.g. usual place of residence, temporary place of residence, penal establishment.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13388link
    The coded value of source of admissionNHS data dictionary :- Source of admission
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13389link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Individual accompanying person
    0 … 1
    prsb03-dataelement-10088link
    Details of the accompanying individual and the extent to which they have provided the information about the person.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-10984link
    Name of individual accompanying person.Free text
    treeblank treeblank treetree cancelled  Role
    0 … 1
    prsb03-dataelement-10985link
    Role of the individual accompanying the person.NHS data dictionary : - Care professional
    treeblank treeblank treetree folder Relationship
    0 … 1
    prsb03-dataelement-10986link
    Relationship of individual accompanying the person.
    treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13517link
    The coded value for relationship to person.FHIR value set: - Relationship type
    treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13518link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treetree draft  Comment
    0 … 1
    prsb03-dataelement-12447link
    Information about the extent to which the accompanying individual provided information about the person.Free text.
    treeblank treetree folder Specialty
    0 … 1
    prsb03-dataelement-10089link
    The specialty e.g. physiotherapy, oncology, mental health etc
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13390link
    The coded value for specialtyNHS data dictionary :- Activity treatment function code
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13391link
    Free text field to be used if no code is availableFree text
    folder Discharge details
    0 … 1
    prsb03-dataelement-191link
    Discharge details
    treetree folder Discharge details record entry
    0 … *
    prsb03-dataelement-10919link
    This is the discharge details record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
    treeblank treetree draft  Date of discharge
    0 … 1
    prsb03-dataelement-10096link
    The date and time of dischargeDate and time
    treeblank treetree draft  Discharge location
    0 … 1
    prsb03-dataelement-10095link
    The hospital the person was discharged from.NHS data dictionary : - Organisation data service
    treeblank treetree folder Discharging consultant
    0 … 1
    prsb03-dataelement-10093link
    The consultant responsible for the person at time of discharge.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-10994link
    The name of the discharging consultantFree text
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-10995link
    The role of the discharging consultantFHIR value set : - sdsjobrole
    treeblank treetree folder Discharge method
    0 … 1
    prsb03-dataelement-10098link
    The method of discharge from hospital e.g. person discharged on clinical advice or with clinical consent; person discharged him/herself or was discharged by a relative or advocate.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13393link
    The coded value for discharge methodNHS data dictionary : - Discharge method
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13394link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Discharging specialty
    0 … 1
    prsb03-dataelement-10094link
    The specialty of the consultant responsible for the person at the time of discharge.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13395link
    The coded value for discharge specialityNHS data dictionary : - Activity treatment function code
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13396link
    Free text field to be used if no code is availableFree text
    treeblank treetree draft  Discharging department
    0 … 1
    prsb03-dataelement-10987link
    The department from which the person is discharged.Free text
    treeblank treetree draft  Legal status on discharge
    0 … 1
    prsb03-dataelement-10097link
    Whether the person was discharged as informal or formal/detained.NHS data dictionary : - Mental health act classification code
    treeblank treetree folder Discharge destination
    0 … 1
    prsb03-dataelement-10099link
    treeblank treeblank treetree draft  Discharge destination
    0 … 1
    prsb03-dataelement-10100link
    The destination of the person on discharge from hospital e.g. usual place of residence, NHS run care home.NHS data dictionary - Discharge destination.
    treeblank treeblank treetree draft  Discharge address
    0 … 1
    prsb03-dataelement-10101link
    Address to which the person is discharged if not the usual place of residence.NHS data dictionary :- Address
    folder Future appointments
    0 … 1
    prsb03-dataelement-10720link
    Details of future appointments.
    treetree folder Future appointments record entry
    0 … *
    prsb03-dataelement-10721link
    This is the future appointments record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
    treeblank treetree draft  Date of appointment
    0 … 1
    prsb03-dataelement-10722link
    Date and time of future appointment.Date and time
    treeblank treetree draft  Appointment status
    0 … 1
    prsb03-dataelement-10723link
    The status of the appointment e.g. proposed, booked, confirmed, rejected.Free text
    treeblank treetree draft  Reason for appointment
    0 … 1
    prsb03-dataelement-10724link
    Reason this appointment is scheduled e.g. diagnosis, investigation, treatment or assessmentFree text
    treeblank treetree folder Location of future appointment
    0 … 1
    prsb03-dataelement-10726link
    The location of the appointment.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13519link
    The coded value for locationNHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13520link
    Free text field to be used if no code is availableFree text
    treeblank treetree draft  Specialty
    0 … 1
    prsb03-dataelement-10727link
    The specialty e.g. physiotherapy, oncology, mental health etc. NHS data dictionary :- Activity treatment function code
    treeblank treetree draft  Service
    0 … 1
    prsb03-dataelement-10728link
    The service being provided.SNOMED CT: - 1127531000000102 |Services simple reference set (foundation metadata concept)|
    treeblank treetree folder Professional to see the person
    0 … 1
    prsb03-dataelement-10729link
    The name and role of the professional e.g. consultant, care worker, nurse consultant.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-12413link
    The name of the professional seeing the person.Free text
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-12414link
    The role of the professional seeing the person.FHIR value set : - sdsjobrole
    folder Vaccinations
    0 … 1
    prsb03-dataelement-10685link
    Details of vaccinations.
    treetree folder Vaccinations record entry
    0 … *
    prsb03-dataelement-10686link

    This is the vaccinations record entry.

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

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

    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-10695link
    The date on which the vaccination was administered or the reported/partial date on which it was reported.Date and time
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-10759link
    The location where the vaccine was administered.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13577link
    The coded value for locationNHS data dictionary: - Organisation data service
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13578link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Performing professional
    0 … 1
    prsb03-dataelement-12184link
    The professional who administered the vaccine.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-12185link
    The name of the professional.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-12186link
    The role the professional has in relation to the person.FHIR value set : - sdsjobrole
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-12187link
    The grade of the professional.Free text
    treeblank treeblank treetree draft  Speciality
    0 … 1
    prsb03-dataelement-12188link
    The specialty of the professional.NHS data dictionary - Main specialty code
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-12189link
    Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-12190link
    The name of the organisation the professional works for.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-12191link
    Contact details of the professionalNHS data dictionary - UK phone number
    treeblank treetree folder Vaccine product
    1 … 1 Mandatory
    prsb03-dataelement-10687link
    The vaccine product administered.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13237link
    The coded value for vaccine product.dm+d (SNOMED) Concept ID AMP (preferred) or VMP term for the vaccine product
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13238link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Manufacturer
    0 … 1
    prsb03-dataelement-10698link
    Name of vaccine manufacturer.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13239link
    The coded value of the manufacturer.SNOMED CT: - DM+D or GS1
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13240link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Vaccine procedure
    1 … 1 Mandatory
    prsb03-dataelement-10688link
    The procedure which was used to administer the vaccine.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13219link
    The coded value for vaccine procedureSNOMED CT :- < 127785005 |Administration of substance to produce immunity, either active or passive (procedure)| or  << 1066171000000108 Seasonal influenza vaccination given by midwife or << 713404003 Vaccination given (code and all its descendants)
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13220link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Body site
    0 … 1
    prsb03-dataelement-10691link
    Body site vaccine was administered.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13222link
    The coded value for body siteSNOMED CT : - ^1127941000000100 |Vaccine body site of administration simple reference set (foundation metadata concept)|
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13223link
    Free text field to be used if no coded text available
    treeblank treetree folder Route
    0 … 1
    prsb03-dataelement-10692link
    How the vaccine entered the body.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13224link
    The coded value for vaccination routeSNOMED CT: - ^999000051000001100 |ePrescribing route of administration simple reference set (foundation metadata concept)|
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13225link
    Free text field to be used if no coded text available
    treeblank treetree folder Indication
    0 … 1
    prsb03-dataelement-10693link
    The clinical indication or reason for administering the vaccine.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13226link
    The coded value for Indication.SNOMED CT:- ^1127601000000107 | Healthcare matters simple reference set (foundation metadata concept) |
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13227link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Dose amount
    0 … 1
    prsb03-dataelement-10694link
    Amount of vaccine administered.
    treeblank treeblank treetree draft  Value
    0 … 1
    prsb03-dataelement-13838link
    The amount of vaccine administeredFree text
    treeblank treeblank treetree draft  Units of measure
    0 … 1
    prsb03-dataelement-13839link
    The units of measure for the dose amountUCUM code
    treeblank treetree draft  Dose sequence
    0 … 1
    prsb03-dataelement-10824link
    Nominal position in a series of vaccines.Numeric value
    treeblank treetree folder Outcome status
    0 … 1
    prsb03-dataelement-10838link
    Whether the vaccine was administered or not, including the reason why
    treeblank treeblank treetree draft  Not given flag
    0 … 1
    prsb03-dataelement-13230link
    Flag to indicate that the vaccination was NOT given at this time by a healthcare professionalFlag: - Yes or No
    treeblank treeblank treetree draft  Vaccination situation (not given reason)
    0 … 1
    prsb03-dataelement-13231link
    The reason why a vaccination was not administered.FHIR value set : - Reason code
    treeblank treetree folder Person completing record
    0 … 1
    prsb03-dataelement-12192link
    Details of the person completing the record.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-12193link
    The name of the person completing the record.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-12194link
    The organisational role of the person completing record.FHIR value set :- SDSjobrole
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-12195link
    The grade of the person completing the record.Free text.
    treeblank treeblank treetree draft  Specialty
    0 … 1
    prsb03-dataelement-12196link
    The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-12197link
    The organisation the person completing the record works for. NHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-12198link
    Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
    treeblank treeblank treetree draft  Date completed
    0 … 1
    prsb03-dataelement-12199link
    The date and time the record was completed.Date and time.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-12200link
    Contact details of the person completing the record.
    NHS data dictionary : - UK telephone number
    treeblank treetree folder Reported
    0 … 1
    prsb03-dataelement-10825link
    Details of the vaccination reported to the professional
    treeblank treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-10837link
    The date or partial date that the reported vaccination was given in the opinion of the person.Date/time
    treeblank treeblank treetree draft  Reported
    0 … 1
    prsb03-dataelement-13849link
    A flag to indicate the information was reported to a professionalFlag: - Yes or No
    treeblank treeblank treetree draft  Report origin
    0 … 1
    prsb03-dataelement-13232link
    The source of the data when the report of the vaccination event is not based on information from the person who administered the vaccine.FHIR value set:- https://www.hl7.org/fhir/valueset-immunization-origin.html
    folder Problem list
    0 … 1
    prsb03-dataelement-10927link
    A summary of the problems that require investigation or treatment.
    treetree folder Problem list record entry
    0 … *
    prsb03-dataelement-10928link
    This is a problem list record entry.

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

    Each record entry is made up of a number of elements or data items.
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-10929link
    The date the problem was identified.Date and time
    treeblank treetree folder Performing professional
    0 … 1
    prsb03-dataelement-12133link
    The professional who identified the problem.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-12134link
    The name of the professional.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-12135link
    The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-12136link
    The grade of the professional.Free text
    treeblank treeblank treetree draft  Speciality
    0 … 1
    prsb03-dataelement-12137link
    The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-12138link
    Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-12139link
    The name of the organisation the professional works for.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-12140link
    Contact details of the professionalNHS data dictionary - UK phone number
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-10931link
    The location the problem was identified.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13242link
    The coded value for location.NHS data dictionary : - Organisation data service code
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13243link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Problem
    1 … 1 Mandatory
    prsb03-dataelement-10932link
    A condition which needs addressing and so is important for every professional to know about when seeing the person.

    Problems may include diagnoses, symptoms, disabilities and social or behavioural issues
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13244link
    The coded value for the problem list.SNOMED CT : - ^1127581000000103 |Health issues simple reference set|
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13245link
    Free text field to be used if no code is availableFree text
    treeblank treetree draft  Onset date
    0 … 1
    prsb03-dataelement-10933link
    A date or estimated date that the problem beganDate and time
    treeblank treetree draft  End Date
    0 … 1
    prsb03-dataelement-10934link
    The date or estimated date the problem was resolved.Date and time.
    treeblank treetree draft  Stage of disease
    0 … 1
    prsb03-dataelement-10935link
    The stage of the disease where relevant.Free text
    treeblank treetree folder Person completing record
    0 … 1
    prsb03-dataelement-12141link
    Details of the person completing the record.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-12142link
    The name of the person completing the record.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-12143link
    The organisational role of the person completing record.FHIR value set :- SDSjobrole
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-12144link
    The grade of the person completing the record.Free text.
    treeblank treeblank treetree draft  Specialty
    0 … 1
    prsb03-dataelement-12145link
    The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-12146link
    The organisation the person completing the record works for. NHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-12147link
    Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
    treeblank treeblank treetree draft  Date completed
    0 … 1
    prsb03-dataelement-12148link
    The date and time the record was completed.Date and time.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-12149link
    Contact details of the person completing the record.
    NHS data dictionary : - UK telephone number
    treeblank treetree draft  Comment
    0 … *
    prsb03-dataelement-10936link
    Supporting text may be given covering the problem.Free text
    folder Procedures and therapies
    0 … 1
    prsb03-dataelement-238link
    The details of any procedures performed. Includes both psychological and medical therapies and procedures (e.g. cognitive behaviour therapy, hip replacement)
    treetree folder Procedure record entry
    0 … *
    prsb03-dataelement-10652link
    This is a procedure record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-10138link
    The date the procedure was performed.Date and time.
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-13246link
    The location where the procedure was undertaken.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13247link
    The coded value for location.NHS data dictionary : - Organisation data service code
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13248link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Performing professional
    0 … 1
    prsb03-dataelement-12150link
    The professional who performed the procedure.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-12151link
    The name of the professional.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-12152link
    The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-12153link
    The grade of the professional.Free text
    treeblank treeblank treetree draft  Speciality
    0 … 1
    prsb03-dataelement-12154link
    The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-12155link
    Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-12156link
    The name of the organisation the professional works for.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-12157link
    Contact details of the professionalNHS data dictionary - UK phone number
    treeblank treetree folder Procedure
    1 … 1 Mandatory
    prsb03-dataelement-10141link
    The therapeutic or diagnostic procedure performed. Includes both psychological and medical therapies and procedures (e.g. cognitive behaviour therapy, or follow-up interventions as a result of physical health checks). Complementary or alternative procedures and therapies should be recorded here.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13249link
    The procedure code.SNOMED CT : - <<71388002 |Procedure| OR <<129125009 |Procedure with explicit context|
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13250link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Anatomical site
    0 … 1
    prsb03-dataelement-10142link
    The body site of the procedure
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13251link
    The coded value of the anatomical site.SNOMED CT :- <123037004 |Body structure (body structure)|
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13252link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Laterality
    0 … 1
    prsb03-dataelement-10143link
    Laterality of the procedure
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13253link
    The coded value for laterality.SNOMED CT:- <182353008 |Side (qualifier value)|
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13254link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Complications related to procedure
    0 … 1
    prsb03-dataelement-10144link
    Details of any intra-operative complications encountered during the procedure, arising during the person’s stay in the recovery unit or directly attributable to the procedure.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13255link
    The coded value for complications relating to procedure.SNOMED CT : - <404684003 |Clinical finding (finding)|
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13256link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Specific anesthesia issues
    0 … 1
    prsb03-dataelement-10145link
    Details of any adverse reaction to any anesthetic agents including local anesthesia. Problematic intubation, transfusion reaction, etc.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13257link
    The coded value for specific anesthesia issues.SNOMED CT
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13258link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Person completing record
    0 … 1
    prsb03-dataelement-12158link
    Details of the person completing the record.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-12159link
    The name of the person completing the record.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-12160link
    The organisational role of the person completing record.FHIR value set :- SDSjobrole
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-12161link
    The grade of the person completing the record.Free text.
    treeblank treeblank treetree draft  Specialty
    0 … 1
    prsb03-dataelement-12162link
    The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-12163link
    The organisation the person completing the record works for. NHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-12164link
    Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
    treeblank treeblank treetree draft  Date completed
    0 … 1
    prsb03-dataelement-12165link
    The date and time the record was completed.Date and time.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-12166link
    Contact details of the person completing the record.
    NHS data dictionary : - UK telephone number
    treeblank treetree draft  Comment
    0 … 1
    prsb03-dataelement-10146link
    Any further textual comment to clarify such as statement that information is partial or incomplete. Also indicate the outcome of the procedure.Free text
    folder Social context
    0 … 1
    prsb03-dataelement-136link
    The social setting in which the person lives, such as their household, occupational history, and lifestyle factors.
    treetree folder Household composition
    0 … 1
    prsb03-dataelement-10036link
    Details of the person's household composition.
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-11770link
    The date when the household composition was taken.Date and time.
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-13271link
    The location where the household composition was taken.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13272link
    The coded value for location.NHS data dictionary : - Organisation data service code
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13273link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Household composition
    0 … 1
    prsb03-dataelement-13261link
    Description of the household composition e.g. lives alone, lives with family, lives with partner, etc.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13262link
    The coded value of household compositionSNOMED CT: - 1027891000000106 | Household composition findings simple reference set (foundation metadata concept) |
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13263link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Performing professional
    0 … 1
    prsb03-dataelement-11648link
    The professional who took the household composition.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-11649link
    The name of the professional.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-11650link
    The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-11651link
    The grade of the professional.Free text
    treeblank treeblank treetree draft  Speciality
    0 … 1
    prsb03-dataelement-11652link
    The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-11653link
    Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-11654link
    The name of the organisation the professional works for.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-11655link
    Contact details of the professionalNHS data dictionary - UK phone number
    treeblank treetree folder Person completing record
    0 … 1
    prsb03-dataelement-11521link
    Details of the person completing the record.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-11522link
    The name of the person completing the record.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-11523link
    The organisational role of the person completing record.FHIR value set :- SDSjobrole
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-11524link
    The grade of the person completing the record.Free text.
    treeblank treeblank treetree draft  Specialty
    0 … 1
    prsb03-dataelement-11525link
    The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-11526link
    The organisation the person completing the record works for. NHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-11527link
    Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
    treeblank treeblank treetree draft  Date completed
    0 … 1
    prsb03-dataelement-11528link
    The date and time the record was completed.Date and time.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-11529link
    Contact details of the person completing the record.
    NHS data dictionary : - UK telephone number
    treetree folder Occupational history
    0 … 1
    prsb03-dataelement-10037link
    The current and/or previous occupation(s) of the person.
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-11772link
    The date when the occupational history was taken.Date and time.
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-11773link
    The location where the occupational history was taken.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13274link
    The coded value for the location.NHS Data dictionary : - Organisation data service code
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13275link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Occupational history
    0 … 1
    prsb03-dataelement-13264link
    The current and/or previous occupation(s) of the person.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13265link
    The coded value for occupational historySNOMED CT : - ^999001571000000109 | Occupation simple reference set (foundation metadata concept)
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13266link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Performing professional
    0 … 1
    prsb03-dataelement-11656link
    The professional who took the occupational history.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-11657link
    The name of the professional.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-11658link
    The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-11659link
    The grade of the professional.Free text
    treeblank treeblank treetree draft  Speciality
    0 … 1
    prsb03-dataelement-11660link
    The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-11661link
    Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-11662link
    The name of the organisation the professional works for.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-11663link
    Contact details of the professionalNHS data dictionary - UK phone number
    treeblank treetree folder Person completing record
    0 … 1
    prsb03-dataelement-11530link
    Details of the person completing the record.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-11531link
    The name of the person completing the record.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-11532link
    The organisational role of the person completing record.FHIR value set :- SDSjobrole
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-11533link
    The grade of the person completing the record.Free text.
    treeblank treeblank treetree draft  Specialty
    0 … 1
    prsb03-dataelement-11534link
    The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-11535link
    The organisation the person completing the record works for. NHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-11536link
    Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
    treeblank treeblank treetree draft  Date completed
    0 … 1
    prsb03-dataelement-11537link
    The date and time the record was completed.Date and time.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-11538link
    Contact details of the person completing the record.
    NHS data dictionary : - UK telephone number
    treetree folder Educational history
    0 … 1
    prsb03-dataelement-10038link
    Details of the person's educational history.
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-11774link
    The date when the educational history was taken.Date and time.
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-11775link
    The location where the education history was taken.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13276link
    The coded value for location.NHS Data dictionary : - Organisation data service code
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13277link
    Free text field to be used if no code is availableFree text
    treeblank treetree draft  Educational history
    0 … 1
    prsb03-dataelement-13840link
    The current and/or previous relevant educational history of the person.Free text
    treeblank treetree folder Performing professional
    0 … 1
    prsb03-dataelement-11776link
    The professional who took the educational history.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-11777link
    The name of the professional.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-11778link
    The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-11779link
    The grade of the professional.Free text
    treeblank treeblank treetree draft  Speciality
    0 … 1
    prsb03-dataelement-11780link
    The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-11781link
    Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-11782link
    The name of the organisation the professional works for.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-11783link
    Contact details of the professionalNHS data dictionary - UK phone number
    treeblank treetree folder Person completing record
    0 … 1
    prsb03-dataelement-11539link
    Details of the person completing the record.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-11540link
    The name of the person completing the record.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-11541link
    The organisational role of the person completing record.FHIR value set :- SDSjobrole
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-11542link
    The grade of the person completing the record.Free text.
    treeblank treeblank treetree draft  Specialty
    0 … 1
    prsb03-dataelement-11543link
    The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-11544link
    The organisation the person completing the record works for. NHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-11545link
    Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
    treeblank treeblank treetree draft  Date completed
    0 … 1
    prsb03-dataelement-11546link
    The date and time the record was completed.Date and time.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-11547link
    Contact details of the person completing the record.
    NHS data dictionary : - UK telephone number
    treetree folder Lifestyle choices
    0 … 1
    prsb03-dataelement-10039link
    The lifestyle choices made by the person which are pertinent to his or her health and well-being, e.g. physical activity level, pets, hobbies and sexual habits
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-11784link
    The date when the lifestyle choices were taken.Date and time.
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-11785link
    The location where the lifestyle choices were taken.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13278link
    The coded value for location.NHS Data dictionary : - Organisation data service code
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13279link
    Free text field to be used if no code is availableFree text
    treeblank treetree draft  Lifestyle choices
    0 … 1
    prsb03-dataelement-13841link
    The lifestyle choices made by the person which are pertinent to his or her health and well-being, e.g. physical activity level, pets, hobbies and sexual preferences.Free text
    treeblank treetree folder Performing professional
    0 … 1
    prsb03-dataelement-11786link
    The professional who took the lifestyle choices.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-11787link
    The name of the professional.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-11788link
    The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-11789link
    The grade of the professional.Free text
    treeblank treeblank treetree draft  Speciality
    0 … 1
    prsb03-dataelement-11790link
    The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-11791link
    Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-11792link
    The name of the organisation the professional works for.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-11793link
    Contact details of the professionalNHS data dictionary - UK phone number
    treeblank treetree folder Person completing record
    0 … 1
    prsb03-dataelement-11548link
    Details of the person completing the record.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-11549link
    The name of the person completing the record.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-11550link
    The organisational role of the person completing record.FHIR value set :- SDSjobrole
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-11551link
    The grade of the person completing the record.Free text.
    treeblank treeblank treetree draft  Specialty
    0 … 1
    prsb03-dataelement-11552link
    The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-11553link
    The organisation the person completing the record works for. NHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-11554link
    Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
    treeblank treeblank treetree draft  Date completed
    0 … 1
    prsb03-dataelement-11555link
    The date and time the record was completed.Date and time.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-11556link
    Contact details of the person completing the record.
    NHS data dictionary : - UK telephone number
    treetree folder Smoking status
    0 … 1
    prsb03-dataelement-10040link
    Details of the person's smoking status.
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-11794link
    The date when the smoking status was taken.Date and time
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-11795link
    The location where the smoking status was taken.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13281link
    The coded value for locationNHS data dictionary : - Organisation data service code
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13282link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Smoking status
    0 … 1
    prsb03-dataelement-13283link
    Record of any smoking use by the person.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13284link
    The smoking status of the person.SNOMED CT:- ^999000891000000102 |Smoking simple reference set (foundation metadata concept)|
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13285link
    Free text field to be used if no code is availableFree text
    treeblank treetree draft  Smoking status - details
    0 … 1
    prsb03-dataelement-13286link
    Further details recorded about the smoking status of the personFree text
    treeblank treetree folder Date stopped smoking
    0 … 1
    prsb03-dataelement-13287link
    The date the person stopped smoking (if known)
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13288link
    The coded value for date stopped smoking.SNOMED CT:- 160625004 |Date ceased smoking (observable entity)|
    treeblank treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-13289link
    The date the person stopped smoking.Date and time
    treeblank treetree folder Performing professional
    0 … 1
    prsb03-dataelement-11796link
    The professional who took the smoking status.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-11797link
    The name of the professional.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-11798link
    The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-11799link
    The grade of the professional.Free text
    treeblank treeblank treetree draft  Speciality
    0 … 1
    prsb03-dataelement-11800link
    The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-11801link
    Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-11802link
    The name of the organisation the professional works for.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-11803link
    Contact details of the professionalNHS data dictionary - UK phone number
    treeblank treetree folder Person completing record
    0 … 1
    prsb03-dataelement-11557link
    Details of the person completing the record.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-11558link
    The name of the person completing the record.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-11559link
    The organisational role of the person completing record.FHIR value set :- SDSjobrole
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-11560link
    The grade of the person completing the record.Free text.
    treeblank treeblank treetree draft  Specialty
    0 … 1
    prsb03-dataelement-11561link
    The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-11562link
    The organisation the person completing the record works for. NHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-11563link
    Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
    treeblank treeblank treetree draft  Date completed
    0 … 1
    prsb03-dataelement-11564link
    The date and time the record was completed.Date and time.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-11565link
    Contact details of the person completing the record.
    NHS data dictionary : - UK telephone number
    treetree folder Alcohol intake
    0 … 1
    prsb03-dataelement-10041link
    Details of the person's alcohol intake
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-11804link
    The date when the alcohol intake was noted.Date and time
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-11805link
    The location where the alcohol intake was noted.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13332link
    The coded value for location.NHS Data dictionary : - Organisation data service code
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13333link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Alcohol intake
    0 … 1
    prsb03-dataelement-13290link
    Latest or current alcohol consumption.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13291link
    The coded value of the person alcohol intakeSNOMED CT :- 219006 |Current drinker of alcohol (finding)| OR 105542008 |Current non-drinker of alcohol (finding)| OR 228274009 |Lifetime non-drinker (finding)| OR 1104551000000109 |Declined to provide information about alcohol use (situation)| OR 371434005 |History of alcohol abuse (situation)|
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13292link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Performing professional
    0 … 1
    prsb03-dataelement-11806link
    The professional who noted the alcohol intake.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-11807link
    The name of the professional.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-11808link
    The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-11809link
    The grade of the professional.Free text
    treeblank treeblank treetree draft  Speciality
    0 … 1
    prsb03-dataelement-11810link
    The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-11811link
    Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-11812link
    The name of the organisation the professional works for.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-11813link
    Contact details of the professionalNHS data dictionary - UK phone number
    treeblank treetree folder Person completing record
    0 … 1
    prsb03-dataelement-11566link
    Details of the person completing the record.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-11567link
    The name of the person completing the record.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-11568link
    The organisational role of the person completing record.FHIR value set :- SDSjobrole
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-11569link
    The grade of the person completing the record.Free text.
    treeblank treeblank treetree draft  Specialty
    0 … 1
    prsb03-dataelement-11570link
    The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-11571link
    The organisation the person completing the record works for. NHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-11572link
    Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
    treeblank treeblank treetree draft  Date completed
    0 … 1
    prsb03-dataelement-11573link
    The date and time the record was completed.Date and time.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-11574link
    Contact details of the person completing the record.
    NHS data dictionary : - UK telephone number
    treetree folder Drug/substance use
    0 … 1
    prsb03-dataelement-10042link
    Details of the person's drug and substance use.
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-11814link
    The date when the drug/substance use was noted.Date and time
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-11815link
    The location where the drug/substance use was noted.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13334link
    The coded value for location.NHS Data dictionary : - Organisation data service code
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13335link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Drug/substance use
    0 … 1
    prsb03-dataelement-13336link
    Latest or current drug/substance use.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13337link
    The coded value for drug and substance misuse.SNOMED CT:- 361055000 |Misuses drugs (finding)| OR 371422002 |History of substance abuse (situation)| OR 228368007 |Has never misused drugs (situation)| OR 783241000000102 |Declined to give substance misuse history (finding)|
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13338link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Performing professional
    0 … 1
    prsb03-dataelement-11816link
    The professional who noted the drug/substance use.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-11817link
    The name of the professional.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-11818link
    The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-11819link
    The grade of the professional.Free text
    treeblank treeblank treetree draft  Speciality
    0 … 1
    prsb03-dataelement-11820link
    The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-11821link
    Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-11822link
    The name of the organisation the professional works for.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-11823link
    Contact details of the professionalNHS data dictionary - UK phone number
    treeblank treetree folder Person completing record
    0 … 1
    prsb03-dataelement-11575link
    Details of the person completing the record.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-11576link
    The name of the person completing the record.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-11577link
    The organisational role of the person completing record.FHIR value set :- SDSjobrole
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-11578link
    The grade of the person completing the record.Free text.
    treeblank treeblank treetree draft  Specialty
    0 … 1
    prsb03-dataelement-11579link
    The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-11580link
    The organisation the person completing the record works for. NHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-11581link
    Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
    treeblank treeblank treetree draft  Date completed
    0 … 1
    prsb03-dataelement-11582link
    The date and time the record was completed.Date and time.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-11583link
    Contact details of the person completing the record.
    NHS data dictionary : - UK telephone number
    treetree folder Social circumstances
    0 … 1
    prsb03-dataelement-10043link
    Details of the persons social circumstances
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-11824link
    The date when the social circumstances were taken.Date and time
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-11825link
    The location where the social circumstances were taken.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13339link
    The coded value for the location
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13340link
    Free text field to be used if no code is availableFree text
    treeblank treetree draft  Social circumstances
    0 … 1
    prsb03-dataelement-13341link
    A person’s social background, network and personal circumstances, e.g. housing. This should include whether the person is a carer.Free text
    treeblank treetree folder Performing professional
    0 … 1
    prsb03-dataelement-11826link
    The professional who took the social circumstances.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-11827link
    The name of the professional.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-11828link
    The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-11829link
    The grade of the professional.Free text
    treeblank treeblank treetree draft  Speciality
    0 … 1
    prsb03-dataelement-11830link
    The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-11831link
    Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-11832link
    The name of the organisation the professional works for.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-11833link
    Contact details of the professionalNHS data dictionary - UK phone number
    treeblank treetree folder Person completing record
    0 … 1
    prsb03-dataelement-11584link
    Details of the person completing the record.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-11585link
    The name of the person completing the record.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-11586link
    The organisational role of the person completing record.FHIR value set :- SDSjobrole
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-11587link
    The grade of the person completing the record.Free text.
    treeblank treeblank treetree draft  Specialty
    0 … 1
    prsb03-dataelement-11588link
    The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-11589link
    The organisation the person completing the record works for. NHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-11590link
    Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
    treeblank treeblank treetree draft  Date completed
    0 … 1
    prsb03-dataelement-11591link
    The date and time the record was completed.Date and time.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-11592link
    Contact details of the person completing the record.
    NHS data dictionary : - UK telephone number
    treetree folder Access
    0 … 1
    prsb03-dataelement-10045link
    Details of access for the person.
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-11844link
    The date when the special access requirements were taken.Date and time
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-11845link
    The location where the special access requirements were taken.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13343link
    The coded value for locationNHS Data dictionary : - Organisation data service code
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13344link
    Free text field to be used if no coded text available
    treeblank treetree draft  Access
    0 … 1
    prsb03-dataelement-13342link
    Special access requirements e.g. key safe, coded lock, which door to use, stretcher access, etc.Free text
    treeblank treetree folder Performing professional
    0 … 1
    prsb03-dataelement-11846link
    The professional who took the special access requirements.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-11847link
    The name of the professional.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-11848link
    The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-11849link
    The grade of the professional.Free text
    treeblank treeblank treetree draft  Speciality
    0 … 1
    prsb03-dataelement-11850link
    The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-11851link
    Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-11852link
    The name of the organisation the professional works for.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-11853link
    Contact details of the professionalNHS data dictionary - UK phone number
    treeblank treetree folder Person completing record
    0 … 1
    prsb03-dataelement-11602link
    Details of the person completing the record.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-11603link
    The name of the person completing the record.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-11604link
    The organisational role of the person completing record.FHIR value set :- SDSjobrole
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-11605link
    The grade of the person completing the record.Free text.
    treeblank treeblank treetree draft  Specialty
    0 … 1
    prsb03-dataelement-11606link
    The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-11607link
    The organisation the person completing the record works for. NHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-11608link
    Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
    treeblank treeblank treetree draft  Date completed
    0 … 1
    prsb03-dataelement-11609link
    The date and time the record was completed.Date and time.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-11610link
    Contact details of the person completing the record.
    NHS data dictionary : - UK telephone number
    treetree folder Dependants
    0 … 1
    prsb03-dataelement-10046link
    Details of any responsibility the person has for dependants.
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-11854link
    The date when the dependents details were taken.Date and time
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-11855link
    The location where the dependents details were taken.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13346link
    The coded value for locationNHS Data dictionary : - Organisation data service code
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13347link
    Free text field to be used if no code is availableFree text
    treeblank treetree draft  Dependants
    0 … 1
    prsb03-dataelement-13345link
    Provide details of any responsibility the person has for dependants. In the case of children provide date of birth of the child.Free text
    treeblank treetree folder Performing professional
    0 … 1
    prsb03-dataelement-11856link
    The professional who took the dependents details.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-11857link
    The name of the professional.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-11858link
    The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-11859link
    The grade of the professional.Free text
    treeblank treeblank treetree draft  Speciality
    0 … 1
    prsb03-dataelement-11860link
    The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-11861link
    Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-11862link
    The name of the organisation the professional works for.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-11863link
    Contact details of the professionalNHS data dictionary - UK phone number
    treeblank treetree folder Person completing record
    0 … 1
    prsb03-dataelement-11611link
    Details of the person completing the record.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-11612link
    The name of the person completing the record.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-11613link
    The organisational role of the person completing record.FHIR value set :- SDSjobrole
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-11614link
    The grade of the person completing the record.Free text.
    treeblank treeblank treetree draft  Specialty
    0 … 1
    prsb03-dataelement-11615link
    The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-11616link
    The organisation the person completing the record works for. NHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-11617link
    Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
    treeblank treeblank treetree draft  Date completed
    0 … 1
    prsb03-dataelement-11618link
    The date and time the record was completed.Date and time.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-11619link
    Contact details of the person completing the record.
    NHS data dictionary : - UK telephone number
    treetree folder Accommodation status
    0 … 1
    prsb03-dataelement-10047link
    Details of the type of accommodation where the person lives.
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-11864link
    The date when the accommodation status was taken.Date and time
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-11865link
    The location where the accommodation was taken.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13352link
    The coded value of locationNHS Data dictionary : - Organisation data service code
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13353link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Accommodation status
    0 … 1
    prsb03-dataelement-13348link
    An indication of the type of accommodation where the person lives.

    This should be based on the main or permanent residence.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13349link
    The coded value for accommodation statusNHS data dictionary :- Accommodation status
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13350link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Performing professional
    0 … 1
    prsb03-dataelement-11866link
    The professional who took the accommodation status.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-11867link
    The name of the professional.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-11868link
    The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-11869link
    The grade of the professional.Free text
    treeblank treeblank treetree draft  Speciality
    0 … 1
    prsb03-dataelement-11870link
    The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-11871link
    Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-11872link
    The name of the organisation the professional works for.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-11873link
    Contact details of the professionalNHS data dictionary - UK phone number
    treeblank treetree folder Person completing record
    0 … 1
    prsb03-dataelement-11874link
    Details of the person completing the record.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-11875link
    The name of the person completing the record.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-11876link
    The organisational role of the person completing record.FHIR value set :- SDSjobrole
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-11877link
    The grade of the person completing the record.Free text.
    treeblank treeblank treetree draft  Specialty
    0 … 1
    prsb03-dataelement-11878link
    The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-11879link
    The organisation the person completing the record works for. NHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-11880link
    Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
    treeblank treeblank treetree draft  Date completed
    0 … 1
    prsb03-dataelement-11881link
    The date and time the record was completed.Date and time.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-11882link
    Contact details of the person completing the record.
    NHS data dictionary : - UK telephone number
    treetree folder Household environment
    0 … 1
    prsb03-dataelement-10051link
    Details of the person's household environment.
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-11883link
    The date when the household environment details were taken.Date and time
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-11884link
    The location where the household environment details were taken.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13351link
    The coded value for locationNHS Data dictionary : - Organisation data service code
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13354link
    Free text field to be used if no code is availableFree text
    treeblank treetree draft  Household environment
    0 … 1
    prsb03-dataelement-13842link
    Factors in the household which impact the person's health and wellbeing, to include smoking in the home, alcohol/substance use etc.Free text
    treeblank treetree folder Performing professional
    0 … 1
    prsb03-dataelement-11885link
    The professional who took the household environment details.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-11886link
    The name of the professional.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-11887link
    The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-11888link
    The grade of the professional.Free text
    treeblank treeblank treetree draft  Speciality
    0 … 1
    prsb03-dataelement-11889link
    The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-11890link
    Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-11891link
    The name of the organisation the professional works for.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-11892link
    Contact details of the professionalNHS data dictionary - UK phone number
    treeblank treetree folder Person completing record
    0 … 1
    prsb03-dataelement-11621link
    Details of the person completing the record.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-11622link
    The name of the person completing the record.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-11623link
    The organisational role of the person completing record.FHIR value set :- SDSjobrole
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-11624link
    The grade of the person completing the record.Free text.
    treeblank treeblank treetree draft  Specialty
    0 … 1
    prsb03-dataelement-11625link
    The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-11626link
    The organisation the person completing the record works for. NHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-11627link
    Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
    treeblank treeblank treetree draft  Date completed
    0 … 1
    prsb03-dataelement-11628link
    The date and time the record was completed.Date and time.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-11629link
    Contact details of the person completing the record.
    NHS data dictionary : - UK telephone number
    folder Services and care
    0 … 1
    prsb03-dataelement-10044link
    The services and care provided for the person.
    treetree folder Services and care record entry
    0 … *
    prsb03-dataelement-12421link
    This is a services and care record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
    treeblank treetree draft  Social care package name
    0 … 1
    prsb03-dataelement-12965link
    Name of specific type of package being provided (e.g. Reablement, Home Based Care XYZ, etc)Free text
    treeblank treetree draft  Social care package type
    0 … 1
    prsb03-dataelement-12966link
    Higher level categorisation of package type, e.g. Adults Home SupportFree text
    treeblank treetree draft  Service start date
    0 … 1
    prsb03-dataelement-11834link
    The date service started to be provided.Date and time
    treeblank treetree draft  Service end date
    0 … 1
    prsb03-dataelement-12420link
    The date the service is planned to be ended or the actual end date.Date and time
    treeblank treetree folder Local authority
    0 … 1
    prsb03-dataelement-11835link
    The name of the local authority providing the care package.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13566link
    The coded value for local authorityNHS data dictionary: - Organisation data service
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13567link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Care funding source
    0 … 1
    prsb03-dataelement-13067link
    A reference to the funding source and any conditions or limitations associated.
    treeblank treetree folder Performing professional
    0 … 1
    prsb03-dataelement-11836link
    The professional providing the service.Free text
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-11837link
    The name of the professional.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-11838link
    The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-11839link
    The grade of the professional.Free text
    treeblank treeblank treetree draft  Speciality
    0 … 1
    prsb03-dataelement-11840link
    The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-11841link
    Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-11842link
    The name of the organisation the professional works for.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-11843link
    Contact details of the professionalNHS data dictionary - UK phone number
    treeblank treetree folder Person completing record
    0 … 1
    prsb03-dataelement-11593link
    Details of the person completing the record.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-11594link
    The name of the person completing the record.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-11595link
    The organisational role of the person completing record.FHIR value set :- SDSjobrole
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-11596link
    The grade of the person completing the record.Free text.
    treeblank treeblank treetree draft  Specialty
    0 … 1
    prsb03-dataelement-11597link
    The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-11598link
    The organisation the person completing the record works for. NHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-11599link
    Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
    treeblank treeblank treetree draft  Date completed
    0 … 1
    prsb03-dataelement-11600link
    The date and time the record was completed.Date and time.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-11601link
    Contact details of the person completing the record.
    NHS data dictionary : - UK telephone number
    folder Primary support reason
    0 … 1
    prsb03-dataelement-12974link
    The primary support reason for social care.
    treetree folder Primary support reason record entry
    0 … *
    prsb03-dataelement-12975link
    This is a primary support reason record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
    treeblank treetree draft  Primary support reason
    0 … 1
    prsb03-dataelement-12976link
    The Primary Support Reason used to classify a person for National Reporting on Short and Long Term Services (SALT) e.g. Learning disability support, mental health support, physical supportFree text
    treeblank treetree draft  Active
    0 … 1
    prsb03-dataelement-13305link
    Flag to indicate whether the primary support reason is currently activeFlag: - Yes or No
    treeblank treetree draft  Start date
    0 … 1
    prsb03-dataelement-13306link
    The date a primary support reason was authorised as active.Date and time
    treeblank treetree draft  End date
    0 … 1
    prsb03-dataelement-13307link
    The end date of authorisation.Date and time
    folder Family history
    0 … 1
    prsb03-dataelement-251link
    Family history
    treetree folder Family history record entry
    0 … 1
    prsb03-dataelement-10653link
    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.
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-10153link
    The date the family history was taken.Date and time
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-10851link
    The location where the family history was taken.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13682link
    The coded value for locationNHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13683link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Performing professional
    0 … 1
    prsb03-dataelement-11640link
    The professional who took the family history.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-11641link
    The name of the professional.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-11642link
    The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-11643link
    The grade of the professional.Free text
    treeblank treeblank treetree draft  Speciality
    0 … 1
    prsb03-dataelement-11644link
    The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-11645link
    Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-11646link
    The name of the organisation the professional works for.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-11647link
    Contact details of the professionalNHS data dictionary - UK phone number
    treeblank treetree folder Relationship to person
    0 … 1
    prsb03-dataelement-10155link
    The relationship of the family member with the condition to the person.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13676link
    The coded value for relationship to personSNOMED CT: - <303071001 |Person in the family (person)|
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13677link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Family history
    0 … 1
    prsb03-dataelement-10151link
    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.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13678link
    The coded value for family historySNOMED CT:- <404684003 |Clinical finding (finding)| OR <243796009 |Situation with explicit context (situation)|
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13679link
    Free text field to be used if no coded text available
    treeblank treetree folder Person completing record
    0 … 1
    prsb03-dataelement-11630link
    Details of the person completing the record.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-11631link
    The name of the person completing the record.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-11632link
    The organisational role of the person completing record.FHIR value set :- SDSjobrole
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-11633link
    The grade of the person completing the record.Free text.
    treeblank treeblank treetree draft  Specialty
    0 … 1
    prsb03-dataelement-11634link
    The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-11635link
    The organisation the person completing the record works for. NHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-11636link
    Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
    treeblank treeblank treetree draft  Date completed
    0 … 1
    prsb03-dataelement-11637link
    The date and time the record was completed.Date and time.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-11638link
    Contact details of the person completing the record.
    NHS data dictionary : - UK telephone number
    treeblank treetree draft  Comment
    0 … 1
    prsb03-dataelement-10156link
    Any further textual comment.Free text
    folder Investigation results
    0 … 1
    prsb03-dataelement-257link
    Investigation results
    treetree folder Investigation results record entry
    0 … *
    prsb03-dataelement-10654link
    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.
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-10157link
    The date and time when the investigation was performedDate and time
    treeblank treetree folder Performing professional
    0 … 1
    prsb03-dataelement-12099link
    The professional who performed the investigation.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-12100link
    The name of the professional.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-12101link
    The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-12102link
    The grade of the professional.Free text
    treeblank treeblank treetree draft  Speciality
    0 … 1
    prsb03-dataelement-12103link
    The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-12104link
    Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-12105link
    The name of the organisation the professional works for.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-12106link
    Contact details of the professionalNHS data dictionary - UK phone number
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-10159link
    The location where the investigation took place.
    treeblank treeblank treetree draft  Coded location
    0 … 1
    prsb03-dataelement-13725link
    The coded value for locationNHS data dictionary : Organisation data service
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13726link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Investigation
    1 … 1 Mandatory
    prsb03-dataelement-10160link
    The investigation performed.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13525link
    The coded value for investigationSNOMED CT: - <71388002 |Procedure (procedure)|
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13526link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Investigation result
    0 … 1
    prsb03-dataelement-10161link
    For each investigation, the result of the investigation. This can include a report which may have results for multiple tests.
    treeblank treeblank treetree draft  Coded value
    0 … *
    prsb03-dataelement-13527link
    The coded value for investigation resultsSNOMED CT:- <404684003 |Clinical finding (finding)| OR <243796009 |Situation with explicit context (situation)|
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13528link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Structured investigation result
    0 … 1
    prsb03-dataelement-12415link
    A structured set of information for each investigation result.
    treeblank treeblank treetree draft  Value
    0 … 1
    prsb03-dataelement-12416link
    The value of the investigation result.Numeric
    treeblank treeblank treetree draft  Units of measure
    0 … 1
    prsb03-dataelement-12417link
    The units of the investigation result.UCUM code
    treeblank treeblank treetree draft  Reference ranges
    0 … 1
    prsb03-dataelement-12418link
    The reference range for the investigation result.Free text
    treeblank treeblank treetree draft  Abnormal indicator
    0 … 1
    prsb03-dataelement-12419link
    Indicator if the investigation is abnormal.Abnormal or Normal
    treeblank treetree folder Person completing record
    0 … 1
    prsb03-dataelement-12107link
    Details of the person completing the record.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-12108link
    The name of the person completing the record.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-12109link
    The organisational role of the person completing record.FHIR value set :- SDSjobrole
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-12110link
    The grade of the person completing the record.Free text.
    treeblank treeblank treetree draft  Specialty
    0 … 1
    prsb03-dataelement-12111link
    The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-12112link
    The organisation the person completing the record works for. NHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-12113link
    Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
    treeblank treeblank treetree draft  Date completed
    0 … 1
    prsb03-dataelement-12114link
    The date and time the record was completed.Date and time.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-12115link
    Contact details of the person completing the record.
    NHS data dictionary : - UK telephone number
    folder Investigations requested
    0 … 1
    prsb03-dataelement-10730link
    Details of any investigations requested
    treetree folder Investigations requested record entry
    0 … *
    prsb03-dataelement-10731link
    This is an investigation requested record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-10732link
    The date the investigation was requested.Date and time
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-10736link
    The location where the investigation was requested.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13727link
    The coded value for locationNHS data dictionary: - Organisation data service
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13728link
    Free text field to be used if no coded text available
    treeblank treetree folder Performing professional
    0 … 1
    prsb03-dataelement-12081link
    The professional who requested the investigation.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-12082link
    The name of the professional.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-12083link
    The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-12084link
    The grade of the professional.Free text
    treeblank treeblank treetree draft  Speciality
    0 … 1
    prsb03-dataelement-12085link
    The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-12086link
    Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-12087link
    The name of the organisation the professional works for.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-12088link
    Contact details of the professionalNHS data dictionary - UK phone number
    treeblank treetree folder Investigation requested
    1 … 1
    prsb03-dataelement-10733link
    The investigation that is requested. The investigation may refer to an individual test or a group of related tests or broader investigation required (so the investigator can determine the appropriate tests)
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13529link
    The coded value for Investigation requestedSNOMED CT: - <71388002 |Procedure (procedure)|
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13530link
    Free text field to be used if no code is availableFree text
    treeblank treetree draft  Status of request
    0 … 1
    prsb03-dataelement-10734link
    The status of the investigation request.Code : - draft | active | suspended | completed | entered-in-error | cancelled
    treeblank treetree draft  Reason for request
    0 … 1
    prsb03-dataelement-10737link
    An explanation or justification for why this investigation is being requested.Free text
    treeblank treetree draft  Request priority
    0 … 1
    prsb03-dataelement-10738link
    The urgency of the investigation requested.Code : - routine | urgent | asap | stat
    treeblank treetree folder Person completing record
    0 … 1
    prsb03-dataelement-12090link
    Details of the person completing the record.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-12091link
    The name of the person completing the record.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-12092link
    The organisational role of the person completing record.FHIR value set :- SDSjobrole
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-12093link
    The grade of the person completing the record.Free text.
    treeblank treeblank treetree draft  Specialty
    0 … 1
    prsb03-dataelement-12094link
    The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-12095link
    The organisation the person completing the record works for. NHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-12096link
    Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
    treeblank treeblank treetree draft  Date completed
    0 … 1
    prsb03-dataelement-12097link
    The date and time the record was completed.Date and time.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-12098link
    Contact details of the person completing the record.
    NHS data dictionary : - UK telephone number
    folder Examination findings
    0 … 1
    prsb03-dataelement-557link
    Examination findings
    treetree folder Examination findings record entry
    0 … *
    prsb03-dataelement-10662link
    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.
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-10462link
    The date the examination was performed.Date and time
    treeblank treetree folder Performing professional
    0 … 1
    prsb03-dataelement-12116link
    The professional who performed the examiniation.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-12117link
    The name of the professional.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-12118link
    The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-12119link
    The grade of the professional.Free text
    treeblank treeblank treetree draft  Speciality
    0 … 1
    prsb03-dataelement-12120link
    The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-12121link
    Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-12122link
    The name of the organisation the professional works for.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-12123link
    Contact details of the professionalNHS data dictionary - UK phone number
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-10461link
    The location where the examination was performed.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13445link
    The coded value for locationNHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13446link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Examination findings
    0 … 1
    prsb03-dataelement-10458link
    The record of findings from the examinations performed.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13443link
    The coded value for examination findingsSNOMED CT : - ^1127601000000107 |Healthcare matters simple reference set (foundation metadata concept)|
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13444link
    Free text field to be used if no coded text available
    treeblank treetree folder Observations
    0 … 1
    prsb03-dataelement-10464link
    The record of essential physiological measurements, e.g., heart rate, blood pressure, temperature, pulse, height, weight, respiratory rate, oxygen saturation.
    treeblank treeblank treetree folder Observations record entry
    0 … *
    prsb03-dataelement-13866link
    This is an observations record entry. There may be 0 to many record entry/entries under a section. Each record entry is made up of a number of elements or data items.
    treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13447link
    The coded value for observationsSNOMED CT: - <363787002 | Observable entity (observable entity) |
    treeblank treeblank treeblank treetree draft  Value
    0 … 1
    prsb03-dataelement-13832link
    The measured value of the observationsEnumerated value e.g. numeric, natural numbers, mild, moderate
    treeblank treeblank treeblank treetree draft  Units of measure
    0 … 1
    prsb03-dataelement-13833link
    The units of measure for the observation.UCUM code
    treeblank treeblank treeblank treetree draft  Site
    0 … 1
    prsb03-dataelement-13848link
    The anatomical site at which the observation is takenSNOMED CT: - 442083009 | Anatomical or acquired body structure (body structure) |
    treeblank treeblank treeblank treetree draft  Interpretation
    0 … 1
    prsb03-dataelement-13843link
    The assessment made based on the result of the observation e.g high, lowFHIR value set: - Interpretation
    treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13448link
    Free text field to be used if no code is availableFree text
    folder Pregnancy status
    0 … 1
    prsb03-dataelement-10814link
    Pregnancy status of the person.
    treetree draft  Date
    0 … 1
    prsb03-dataelement-10812link
    The date the observation was recordedDate and time
    treetree folder Location
    0 … 1
    prsb03-dataelement-10855link
    The location where the pregnancy state details were recorded.
    treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13531link
    The coded value for location.NHS data dictionary: - Organisation data service
    treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13532link
    Free text field to be used if no code is availableFree text
    treetree draft  Pregnancy state
    0 … 1
    prsb03-dataelement-10815link
    A flag that indicates whether the person is pregnant.Flag : - Yes or No
    treetree draft  Expected delivery date
    0 … 1
    prsb03-dataelement-10813link
    The expected delivery date of the person.Date and time
    treetree folder Performing professional
    0 … 1
    prsb03-dataelement-13533link
    The professional who observed the pregnancy
    treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-13534link
    The name of the professional.Free text.
    treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-13535link
    The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
    treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-13536link
    The grade of the professional.Free text
    treeblank treetree draft  Speciality
    0 … 1
    prsb03-dataelement-13537link
    The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
    treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-13538link
    Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
    treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-13539link
    The name of the organisation the professional works for.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13540link
    The coded value for locationNHS data dictionary: - Organisation data service
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13541link
    Free text field to be used if no code is availableFree text
    treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-13542link
    Contact details of the professionalNHS data dictionary - UK phone number
    treetree folder Person completing record
    0 … 1
    prsb03-dataelement-13543link
    Details of the person completing the record.
    treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-13544link
    The name of the person completing the record.Free text.
    treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-13545link
    The organisational role of the person completing record.FHIR value set :- SDSjobrole
    treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-13546link
    The grade of the person completing the record.Free text.
    treeblank treetree draft  Specialty
    0 … 1
    prsb03-dataelement-13547link
    The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
    treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-13548link
    The organisation the person completing the record works for. NHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13549link
    The coded value for locationNHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13550link
    Free text field to be used if no code is availableFree text
    treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-13551link
    Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
    treeblank treetree draft  Date completed
    0 … 1
    prsb03-dataelement-13552link
    The date and time the record was completed.Date and time.
    treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-13553link
    Contact details of the person completing the record.
    NHS data dictionary : - UK telephone number
    folder Assessments
    0 … 1
    prsb03-dataelement-262link
    Details of the person's assessments
    treetree folder Assessments record entry
    0 … *
    prsb03-dataelement-11664link
    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.
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-10763link
    The date the assessment was done.Date and time.
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-10764link
    The location where the assessment was done.ODS code or free text.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13570link
    The coded value for locationNHS data dictionary: - Organisation data service
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13571link
    Free text field to be used if no code is availableFree text
    treeblank treetree draft  Assessment type
    0 … 1
    prsb03-dataelement-10822link
    The type of the assessment e.g. social care needs assessment.Free text
    treeblank treetree draft  Assessment summary
    0 … 1
    prsb03-dataelement-10754link
    The summary of the assessmentFree text
    treeblank treetree folder Structured assessment
    0 … 1
    prsb03-dataelement-10655link
    Details of the structured assessment.
    treeblank treeblank treetree draft  Structured assessment name
    0 … 1
    prsb03-dataelement-11751link
    Structured assessment name e.g. New York Heart Failure, Glasgow Coma scale, Activities of Daily Living (ADL) etc.SNOMED CT
    treeblank treeblank treetree draft  Assessment score
    0 … 1
    prsb03-dataelement-10162link
    The structured assessment score.Free text.
    treeblank treeblank treetree draft  Assessment value
    0 … 1
    prsb03-dataelement-10163link
    The structured assessment value.Numeric
    treeblank treeblank treetree draft  Subscale score
    0 … *
    prsb03-dataelement-10169link
    The subscale score of the structured assessment.Free text.
    treeblank treeblank treetree draft  Subscale value
    0 … *
    prsb03-dataelement-10170link
    The subscale value of the structured assessment.Numeric
    treeblank treetree folder Performing professional
    0 … 1
    prsb03-dataelement-12382link
    The professional who did the assessment.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-12383link
    The name of the professional.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-12384link
    The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-12385link
    The grade of the professional.Free text
    treeblank treeblank treetree draft  Speciality
    0 … 1
    prsb03-dataelement-12386link
    The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-12387link
    Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-12388link
    The name of the organisation the professional works for.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-12389link
    Contact details of the professionalNHS data dictionary - UK phone number
    treeblank treetree folder Person completing record
    0 … 1
    prsb03-dataelement-11752link
    Details of the person completing the record.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-11753link
    The name of the person completing the record.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-11754link
    The organisational role of the person completing record.FHIR value set :- SDSjobrole
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-11755link
    The grade of the person completing the record.Free text.
    treeblank treeblank treetree draft  Specialty
    0 … 1
    prsb03-dataelement-11756link
    The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-11757link
    The organisation the person completing the record works for. NHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-11758link
    Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
    treeblank treeblank treetree draft  Date completed
    0 … 1
    prsb03-dataelement-11759link
    The date and time the record was completed.Date and time.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-11760link
    Contact details of the person completing the record.
    NHS data dictionary : - UK telephone number
    treeblank treetree draft  Comment
    0 … 1
    prsb03-dataelement-10164link
    Supporting text may be given regarding the assessment.Free text
    folder Formulation
    0 … 1
    prsb03-dataelement-11666link
    Details of the person's formulation.
    treetree folder Formulation record entry
    0 … *
    prsb03-dataelement-11667link
    This is the formulation record entry. There may be 0 to many record entry/entries under a section. Each record entry is made up of a number of elements or data items.
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-11669link
    The date the formulation was made.Date and time.
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-11670link
    The location where the formulation was made.NHS data dictionary: - Organisation data service
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13572link
    The coded value for locationNHS data dictionary: - Organisation data service
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13573link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Performing professional
    0 … 1
    prsb03-dataelement-11671link
    The professional who made the formulation.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-11672link
    The name of the professional.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-11673link
    The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-11674link
    The grade of the professional.Free text
    treeblank treeblank treetree draft  Speciality
    0 … 1
    prsb03-dataelement-11675link
    The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-11676link
    Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-11677link
    The name of the organisation the professional works for.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-11678link
    Contact details of the professionalNHS data dictionary - UK phone number
    treeblank treetree draft  Formulation
    1 … 1 Mandatory
    prsb03-dataelement-11668link
    An account, shared by a therapist and person, of the personal meaning and origins of a person’s difficulties. This is viewed in the context of multiple factors including relationships, social circumstances and life events and will indicate the most helpful way forward.Free text
    treeblank treetree folder Person completing record
    0 … 1
    prsb03-dataelement-14411link
    Details of the person completing the record.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-14412link
    The name of the person completing the record.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-14413link
    The organisational role of the person completing record.FHIR value set :- SDSjobrole
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-14414link
    The grade of the person completing the record.Free text.
    treeblank treeblank treetree draft  Specialty
    0 … 1
    prsb03-dataelement-14415link
    The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-14416link
    The organisation the person completing the record works for. NHS data dictionary : - Organisation data service
    treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-14417link
    The coded value for locationNHS data dictionary : - Organisation data service
    treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-14418link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-14419link
    Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
    treeblank treeblank treetree draft  Date completed
    0 … 1
    prsb03-dataelement-14420link
    The date and time the record was completed.Date and time.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-14421link
    Contact details of the person completing the record.
    NHS data dictionary : - UK telephone number
    folder Risks
    0 … 1
    prsb03-dataelement-276link
    Details of any risks related to the person.
    treetree folder Risks
    0 … *
    prsb03-dataelement-14460link
    Details of the persons risks
    treeblank treetree draft  Start date of risk
    0 … 1
    prsb03-dataelement-14461link
    The start date of the risk.Date and time
    treeblank treetree draft  End date of risk
    0 … 1
    prsb03-dataelement-14462link
    The date the risk ended.Date and time
    treeblank treetree draft  Risk
    0 … 1
    prsb03-dataelement-14463link
    The risk to the person or others, this include's any risk the person might cause to them self or to others. e.g. suicide, self harmSNOMED CT: - <281694009 |Finding of at risk (finding)|
    treeblank treetree draft  Risk type
    0 … 1
    prsb03-dataelement-14485link
    The type of risk being recorded e.g. self, to others, from others, risk of accidents, risk of infection and other risksFree text
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-14464link
    The location where the risk was identified.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-14465link
    The coded value for locationNHS data dictionary : - Organisation service code
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-14466link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Performing professional
    0 … 1
    prsb03-dataelement-14467link
    The professional who identified the risk.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-14468link
    The name of the professional.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-14469link
    The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-14470link
    The grade of the professional.Free text
    treeblank treeblank treetree draft  Speciality
    0 … 1
    prsb03-dataelement-14471link
    The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-14472link
    Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-14473link
    The name of the organisation the professional works for.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-14474link
    Contact details of the professionalNHS data dictionary - UK phone number
    treeblank treetree folder Person completing record
    0 … 1
    prsb03-dataelement-14475link
    Details of the person completing the record.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-14476link
    The name of the person completing the record.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-14477link
    The organisational role of the person completing record.FHIR value set :- SDSjobrole
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-14478link
    The grade of the person completing the record.Free text.
    treeblank treeblank treetree draft  Specialty
    0 … 1
    prsb03-dataelement-14479link
    The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-14480link
    The organisation the person completing the record works for. NHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-14481link
    Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
    treeblank treeblank treetree draft  Date completed
    0 … 1
    prsb03-dataelement-14482link
    The date and time the record was completed.Date and time.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-14483link
    Contact details of the person completing the record.
    NHS data dictionary : - UK telephone number
    folder Allergies and adverse reactions
    0 … 1
    prsb03-dataelement-282link
    Allergies and adverse reactions
    treetree folder Allergies and adverse reactions record entry
    0 … *
    prsb03-dataelement-10657link
    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.
    treeblank treetree draft  Type of reaction
    0 … 1
    prsb03-dataelement-10186link
    The type of reaction experienced by the person (allergic, adverse, intolerance)FHIR value set :- Allergy, Intolerance
    treeblank treetree folder Causative agent
    1 … 1 Mandatory
    prsb03-dataelement-10182link
    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”
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13441link
    The coded value for causative agent 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)
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13442link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Reaction details cluster
    0 … *
    prsb03-dataelement-10658link
    Details of the reaction.
    treeblank treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-10190link
    The date that the reaction was identified.Date and time
    treeblank treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-10846link
    Details of where the allergy was identified. Linked to the date of the diagnosis by the professional.
    treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13439link
    The coded value for location.NHS data dictionary : - Organisation data service
    treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13440link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treetree folder Substance
    0 … 1
    prsb03-dataelement-11665link
    The substance, or a class of substances, that is considered to be responsible for the adverse reaction.
    treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13554link
    The coded value for substanceSNOMED CT : - <105590001 | Substance (substance) | or <373873005 | Pharmaceutical / biologic product (product) |
    treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13555link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treetree folder Description of reaction
    0 … 1
    prsb03-dataelement-10183link
    A description of the manifestation of the allergic or adverse reaction experienced by the person. For example, skin rash.
    treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13556link
    The coded value for description of reaction.SNOMED CT: - ^1127581000000103 |Health issues simple reference set|
    treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13557link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treetree draft  Onset date
    0 … 1
    prsb03-dataelement-13844link
    Date and time when manifestations showed e.g could be at home a few days earlier than the contactDate and time
    treeblank treeblank treetree folder Severity
    0 … 1
    prsb03-dataelement-10184link
    A description of the severity of the reaction.
    treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13558link
    The coded value for severityFHIR value set : - Severity
    treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13559link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treetree folder Certainty
    0 … 1
    prsb03-dataelement-10185link
    A description of the certainty that the stated causative agent caused the allergic or adverse reaction.
    treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13560link
    The coded value for certainty.FHIR value set : - Certainty
    treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13561link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treetree folder Route of exposure
    0 … 1
    prsb03-dataelement-13856link
    The route the person was exposed to the substance
    treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13857link
    The coded value for route of exposureSNOMED CT: - ^999000051000001100 |ePrescribing route of administration simple reference set|
    treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13858link
    Free text field to be used if no coded text available
    treeblank treeblank treetree draft  Comment
    0 … 1
    prsb03-dataelement-10189link
    Any additional comment or clarification about the adverse reaction.Free text
    treeblank treetree draft  Evidence
    0 … 1
    prsb03-dataelement-10187link
    Results of investigations that confirmed the certainty of the diagnosis. Examples might include results of skin prick allergy testsFree text
    treeblank treetree draft  Date first experienced
    0 … 1
    prsb03-dataelement-10188link
    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)Date and time
    treeblank treetree draft  Allergy end date
    0 … 1
    prsb03-dataelement-14253link
    The date the allergy was diagnosed as endedDate and time 
    treeblank treetree draft  Comment
    0 … 1
    prsb03-dataelement-14273link
    Any further comments on the person's allergies or adverse reactions.Free text
    treeblank treetree folder Performing professional
    0 … 1
    prsb03-dataelement-12010link
    The professional who identified the reaction.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-12011link
    The name of the professional.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-12012link
    The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-12013link
    The grade of the professional.Free text
    treeblank treeblank treetree draft  Speciality
    0 … 1
    prsb03-dataelement-12014link
    The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-12015link
    Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-12016link
    The name of the organisation the professional works for.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-12017link
    Contact details of the professionalNHS data dictionary - UK phone number
    treeblank treetree folder Person completing record
    0 … 1
    prsb03-dataelement-12018link
    Details of the person completing the record.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-12019link
    The name of the person completing the record.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-12020link
    The organisational role of the person completing record.FHIR value set :- SDSjobrole
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-12021link
    The grade of the person completing the record.Free text.
    treeblank treeblank treetree draft  Specialty
    0 … 1
    prsb03-dataelement-12022link
    The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-12023link
    The organisation the person completing the record works for. NHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-12024link
    Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
    treeblank treeblank treetree draft  Date completed
    0 … 1
    prsb03-dataelement-12025link
    The date and time the record was completed.Date and time.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-12026link
    Contact details of the person completing the record.
    NHS data dictionary : - UK telephone number
    folder Medications and medical devices
    0 … 1
    prsb03-dataelement-636link
    Medications and medical devices
    treetree folder Medication item entry
    0 … *
    prsb03-dataelement-10663link
    All medications and devices that can be prescribed to be entered via this Medication item entry. Handles details of continuation / addition / amendment of admission medications.
    treeblank treetree folder Medication item cluster
    0 … 1
    prsb03-dataelement-10664link
    Medication item cluster
    treeblank treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-10843link
    The date on which the medication or medical device was prescribed.Date and time
    treeblank treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-10844link
    The location where the medication or the medical device was prescribed.
    treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13620link
    The coded value for locationNHS data dictionary : - Organisation data service
    treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13621link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treetree folder Performing professional
    0 … 1
    prsb03-dataelement-12002link
    The professional who prescribed the medication or medical device.
    treeblank treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-12003link
    The name of the professional.Free text.
    treeblank treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-12004link
    The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
    treeblank treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-12005link
    The grade of the professional.Free text
    treeblank treeblank treeblank treetree draft  Speciality
    0 … 1
    prsb03-dataelement-12006link
    The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
    treeblank treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-12007link
    Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
    treeblank treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-12008link
    The name of the organisation the professional works for.
    treeblank treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-12009link
    Contact details of the professionalNHS data dictionary - UK phone number
    treeblank treeblank treetree draft  Medication prescribed by
    0 … 1
    prsb03-dataelement-14316link
    The type of organisation responsible for authorising and issuing the medication e.g. GP
    FHIR value set : - Medication prescribing agency
    treeblank treeblank treetree folder Medication name
    1 … 1 Mandatory
    prsb03-dataelement-10536link
    May be generic name or brand name.
    treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13622link
    The coded value for medication namedm+d:- any code from the VTM, VMP, AMP, VMPP and AMPP concept classes
    treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13623link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treetree folder Medication trade family
    0 … 1
    prsb03-dataelement-14283link
    The trade family or brand of the medication prescribed.
    treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-14320link
    The coded value for medication trade family or brand.SNOMED CT: - 999000641000001107 | National Health Service dictionary of medicines and devices trade family group simple reference set (foundation metadata concept) |
    treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-14321link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treetree folder Form
    0 … 1
    prsb03-dataelement-10537link
    The form of the medication e.g. capsule, drops, tablet, lotion etc.
    treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13624link
    The coded value for form.SNOMED CT: - ^999000781000001107 | National Health Service dictionary of medicines and devices dose form simple reference set (foundation metadata concept) |
    treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13625link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treetree folder Quantity supplied
    0 … 1
    prsb03-dataelement-10539link
    The quantity of the medication (e.g. tablets, inhalers, etc.) provided to the person. This may be dispensed by the pharmacy or on the ward. Record in a structured format i.e. value and a unitFree text
    treeblank treeblank treeblank treetree draft  Value
    0 … 1
    prsb03-dataelement-14271link
    The value of the quantity suppliedEnumerated value
    treeblank treeblank treeblank treetree draft  Unit of measure
    0 … 1
    prsb03-dataelement-14272link
    Unit of measure of quantity suppliedUCUM code
    treeblank treeblank treetree draft  Date supplied
    0 … 1
    prsb03-dataelement-13792link
    The date/time the medication was supplied.Date and time
    treeblank treeblank treetree folder Route
    0 … 1
    prsb03-dataelement-10538link
    The route by which the medication is administered e.g. oral, IM, IV
    treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13655link
    The coded value for routeSNOMED CT: - ^999000051000001100 |ePrescribing route of administration simple reference set (foundation metadata concept)|
    treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13656link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treetree folder Site
    0 … 1
    prsb03-dataelement-10540link
    The anatomical site at which the medication is to be administered.
    treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13657link
    The coded value for siteSNOMED CT: - <442083009 | Anatomical or acquired body structure (body structure) |
    treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13658link
    Free text field to be used when code is not availableFree text
    treeblank treeblank treetree folder Method
    0 … 1
    prsb03-dataelement-10541link
    The technique or method by which the medication is to be administered.
    treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13845link
    The coded value for methodSNOMED CT : - ^999000041000001103 | ePrescribing method simple reference set (foundation metadata concept) |
    treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13846link
    Free text field to be used if no coded text available
    treeblank treeblank treetree draft  Over the counter medication flag
    0 … 1
    prsb03-dataelement-13379link
    Indicates if the medication or device is acquired without a prescription i.e. got by the person over the counterFlag : - Yes or No
    treeblank treeblank treetree folder Structured dose direction cluster
    0 … 1
    prsb03-dataelement-11639link
    A structural representation of the elements carried by the dose syntax in 'parsable dose strength / timing' i.e. dose strength, dose timing, dose duration and maximum dose.
    treeblank treeblank treeblank treetree draft  Dose type
    0 … 1
    prsb03-dataelement-14455link
    The kind of rate or dose specified Calculated or ordered
    treeblank treeblank treeblank treetree folder Structured dose amount
    0 … 1
    prsb03-dataelement-10554link
    A structural representation of dose amount, e.g. 20mg or 2 tablets. This element will generally only be used when persisting data within systems with 'parsable dose directions' being used to exchange the same information between systems. As per FHIR Dose Syntax Implementation Guidance (NHS Digital): https://simplifier.net/guide/DoseSyntaxImplementationGuidanceforFHIRR4/Home
    treeblank treeblank treeblank treeblank treetree draft  Dose
    0 … 1
    prsb03-dataelement-14456link
    Amount of dose medication .Note that this specifies the quantity of the specified medication, not the quantity for each active ingredient(s). Each ingredient amount can be communicated in the Medication resource. For example, if one wants to communicate that a tablet was 375 mg, where the dose was one tablet, you can use the Medication resource to document that the tablet was comprised of 375 mg of drug XYZ. Alternatively if the dose was 375 mg, then you may only need to use the Medication resource to indicate this was a tablet. If the example were an IV such as dopamine and you wanted to communicate that 400mg of dopamine was mixed in 500 ml of some IV solution, then this would all be communicated in the Medication resource. If the administration is not intended to be instantaneous (rate is present or timing has a duration), this can be specified to convey the total amount to be administered over the period of time as indicated by the schedule e.g. 500 ml in dose, with timing used to convey that this should be done over 4 hours.Numeric
    treeblank treeblank treeblank treeblank treetree draft  Rate
    0 … 1
    prsb03-dataelement-14457link
    Amount of medication per unit of time. Identifies the speed with which the medication was or will be introduced into the patient. Typically the rate for an infusion e.g. 100 ml per 1 hour or 100 ml/hr. May also be expressed as a rate per unit of time e.g. 500 ml per 2 hours. Other examples: 200 mcg/min or 200 mcg/1 minute; 1 liter/8 hours. Sometimes, a rate can imply duration when expressed as total volume / duration (e.g. 500mL/2 hours implies a duration of 2 hours). However, when rate doesn't imply duration (e.g. 250mL/hour), then the timing.repeat.duration is needed to convey the infuse over time period.Numeric
    treeblank treeblank treeblank treetree draft  Structured dose timing
    0 … 1
    prsb03-dataelement-10555link
    A slot containing a structural, computable representation of dose timing and maximum dose. This element will generally only be used when persisting data within systems with 'parsable dose directions' being used to exchange the same information between systems. As per FHIR Dose Syntax Implementation Guidance (NHS Digital): https://simplifier.net/guide/DoseSyntaxImplementationGuidanceforFHIRR4/Home Numeric
    treeblank treeblank treeblank treetree draft  Dose direction duration
    0 … 1
    prsb03-dataelement-10548link
    Recommendation of the time period for which the medication should be continued, including direction not to discontinue. As per FHIR Dose Syntax Implementation Guidance (NHS Digital): https://simplifier.net/guide/DoseSyntaxImplementationGuidanceforFHIRR4/Home Numeric
    treeblank treeblank treeblank treetree draft  Dose directions description
    0 … 1
    prsb03-dataelement-10544link
    Describes the entire medication dosage and administration directions including dose quantity and medication frequency and optionally duration e.g. “1 tablet at night" or “2mg at 10pm”.Free text
    treeblank treeblank treeblank treetree draft  Maxdoseperperiod
    0 … 1
    prsb03-dataelement-14458link
    The maximum total quantity of a therapeutic substance that may be administered to a subject over the period of time. For example, 1000mg in 24 hours.Numeric
    treeblank treeblank treeblank treetree draft  Maxdoseperadministration
    0 … 1
    prsb03-dataelement-14459link
    The maximum total quantity of a therapeutic substance that may be administered to a subject per administration.Numeric
    treeblank treeblank treetree folder Repeat medication
    0 … 1
    prsb03-dataelement-14317link
    Is the medication prescribed to be repeated
    treeblank treeblank treeblank treetree draft  Number of repeat prescriptions
    0 … 1
    prsb03-dataelement-14318link
    The number of repeated prescriptionsNumeric
    treeblank treeblank treeblank treetree draft  Review date
    0 … 1
    prsb03-dataelement-14319link
    Date to review the repeat medication prescribed to the personDate and time
    treeblank treeblank treetree draft  Additional instructions
    0 … 1
    prsb03-dataelement-10545link
    Allows for: requirements for adherence support, e.g. compliance aids, prompts and packaging requirements, additional information about specific medicines e.g. where specific brand required, person requirements, e.g. unable to swallow tablets.FHIR value set : - Additional instruction
    treeblank treeblank treetree folder Course details cluster
    0 … 1
    prsb03-dataelement-10561link
    Details of the overall course of medication.
    treeblank treeblank treeblank treetree draft  Course status
    0 … 1
    prsb03-dataelement-10666link
    The status of this prescription.FHIR value set : - Medication status
    treeblank treeblank treeblank treetree draft  Indication
    0 … 1
    prsb03-dataelement-10546link
    Reason for medication being prescribed, where known.Free text
    treeblank treeblank treeblank treetree draft  Start date/time
    0 … 1
    prsb03-dataelement-10667link
    The date and/or time that the medication course should begin.Date and time
    treeblank treeblank treeblank treetree draft  End date/time
    0 … 1
    prsb03-dataelement-10557link
    The date and/or time that the medication course should finish.Date and time
    treeblank treeblank treeblank treetree draft  Link to indication record
    0 … 1
    prsb03-dataelement-10668link
    A link to the record which contains the indication for this medication order.Free text with URL
    treeblank treeblank treeblank treetree draft  Comment/recommendation
    0 … 1
    prsb03-dataelement-10547link
    Suggestions about duration and/or review, ongoing monitoring requirements, advice on starting, discontinuing or changing medication. Additional comment or recommendation about the medication course e.g. 'Patient named supply', 'unlicensed medication', 'Foreign brand' or monitoring recommendationsFree text
    treeblank treeblank treetree folder Medication change summary cluster
    0 … 1
    prsb03-dataelement-10568link
    Records the changes made to medication.
    treeblank treeblank treeblank treetree draft  Status
    0 … 1
    prsb03-dataelement-10669link
    The nature of any change made to the medication.FHIR value set : Medication status
    treeblank treeblank treeblank treetree draft  Indication
    0 … 1
    prsb03-dataelement-10670link
    Reason for change in medication, e.g. sub-therapeutic dose, person intolerant. SNOMED CT:- ^1127601000000107 | Healthcare matters simple reference set (foundation metadata concept) |
    treeblank treeblank treeblank treetree draft  Date of change
    0 … 1
    prsb03-dataelement-10671link
    The date of the change - addition, or amendmentDate and time
    treeblank treeblank treeblank treetree draft  Description of amendment
    0 … 1
    prsb03-dataelement-10672link
    Where a change is made to the medication i.e. one drug stopped and another started or eg dose, frequency or route is changed.Free text
    treeblank treeblank treetree folder Person completing record
    0 … 1
    prsb03-dataelement-11993link
    Details of the person completing the record.
    treeblank treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-11994link
    The name of the person completing the record.Free text.
    treeblank treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-11995link
    The organisational role of the person completing record.FHIR value set :- SDSjobrole
    treeblank treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-11996link
    The grade of the person completing the record.Free text.
    treeblank treeblank treeblank treetree draft  Specialty
    0 … 1
    prsb03-dataelement-11997link
    The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
    treeblank treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-11998link
    The organisation the person completing the record works for. NHS data dictionary : - Organisation data service
    treeblank treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-11999link
    Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
    treeblank treeblank treeblank treetree draft  Date completed
    0 … 1
    prsb03-dataelement-12000link
    The date and time the record was completed.Date and time.
    treeblank treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-12001link
    Contact details of the person completing the record.
    NHS data dictionary : - UK telephone number
    treeblank treetree folder Medical devices entry
    0 … *
    prsb03-dataelement-10583link
    Medical devices
    treeblank treeblank treetree draft  Medical device
    0 … 1
    prsb03-dataelement-10673link
    Any medical device that isn't prescribed.Free text
    treeblank treeblank treetree draft  Comments
    0 … 1
    prsb03-dataelement-11280link
    Any information regarding the medical device.Free text
    treeblank treetree folder Medication discontinued entry
    0 … *
    prsb03-dataelement-10576link
    Medication discontinued entry
    treeblank treeblank treetree folder Name of discontinued medication
    0 … 1
    prsb03-dataelement-10577link
    The name of the medication or medical device being discontinued
    treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13659link
    The coded value for medication name dm+d:- any code from the VTM, VMP, AMP, VMPP and AMPP concept classes
    treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13660link
    Amount of vaccine administered.Free text
    treeblank treeblank treetree draft  Status
    0 … 1
    prsb03-dataelement-12472link
    The status of any change made to the medication. MUST CONTAIN STOPPED.FHIR value set: - Medication status
    treeblank treeblank treetree draft  Indication
    0 … 1
    prsb03-dataelement-10579link
    The clinical indication for any changes in medication status SNOMED CT:- ^1127601000000107 | Healthcare matters simple reference set (foundation metadata concept) |
    treeblank treeblank treetree draft  Date of change
    0 … 1
    prsb03-dataelement-10580link
    The date of the discontinuationDate and time
    treeblank treeblank treetree draft  Comment
    0 … 1
    prsb03-dataelement-10582link
    Any additional comment about the discontinuation or amendment.Free text
    folder Equipment and adaptations
    0 … 1
    prsb03-dataelement-12969link
    Details of equipment/asset (or modifications) that the Local Authority has provided to the patient.
    treetree folder Equipment record entry
    0 … *
    prsb03-dataelement-12970link
    This is a equipment record entry. There may be 1 to many record entries under a section.
    treeblank treetree folder Equipment name
    0 … 1
    prsb03-dataelement-12971link
    The name of the equipment (e.g. 'Keysafe', 'Handrail' 'Lifeline Alarm', etc.)
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13780link
    The coded value for equipment nameSNOMED CT
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13782link
    Free text field to be used if no code is availableFree text
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-13066link

    The date the equipment was issued.Date and time
    treeblank treetree draft  Comment
    0 … 1
    prsb03-dataelement-12972link
    Any further details about the equipment, e.g. position of handrail(s) within the person's homeFree text
    folder Plan and requested actions
    0 … 1
    prsb03-dataelement-535link
    The details of planned investigations, procedures and treatment, and whether this plan has been agreed with the person or their legitimate representative.
    treetree folder Plan and requested actions record entry
    0 … *
    prsb03-dataelement-10661link
    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.
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-10445link
    The date on which the plan and requested actions were prepared.Date and time
    treeblank treetree folder Performing professional
    0 … 1
    prsb03-dataelement-12167link
    The professional who prepared the plan and requested actions.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-12168link
    The name of the professional.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-12169link
    The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-12170link
    The grade of the professional.Free text
    treeblank treeblank treetree draft  Speciality
    0 … 1
    prsb03-dataelement-12171link
    The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-12172link
    Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-12173link
    The name of the organisation the professional works for.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-12174link
    Contact details of the professionalNHS data dictionary - UK phone number
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-10842link
    The location where the plan and requested actions were prepared.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13684link
    The coded value for locationNHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13685link
    Free text field to be used if no code is availableFree text
    treeblank treetree draft  Actions for professionals
    0 … 1
    prsb03-dataelement-10436link
    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.Free text
    treeblank treetree draft  Actions for person or their carer
    0 … 1
    prsb03-dataelement-10437link
    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.Free text
    treeblank treetree draft  Agreed with the person or their legitimate representative
    0 … 1
    prsb03-dataelement-10438link
    Indicates whether the person or their legitimate representative has agreed the entire plan or individual aspects of treatment, expected outcomes, risks and alternative treatments. A record of the agreement of the decisions made.Free text
    treeblank treetree draft  Outcome of plan and requested actions
    0 … *
    prsb03-dataelement-10950link
    The details of the outcome of the plan and requested actions.Free text.
    treeblank treetree folder Person completing record
    0 … 1
    prsb03-dataelement-12175link
    Details of the person completing the record.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-12176link
    The name of the person completing the record.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-12177link
    The organisational role of the person completing record.FHIR value set :- SDSjobrole
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-12178link
    The grade of the person completing the record.Free text.
    treeblank treeblank treetree draft  Specialty
    0 … 1
    prsb03-dataelement-12179link
    The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-12180link
    The organisation the person completing the record works for. NHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-12181link
    Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
    treeblank treeblank treetree draft  Date completed
    0 … 1
    prsb03-dataelement-12182link
    The date and time the record was completed.Date and time.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-12183link
    Contact details of the person completing the record.
    NHS data dictionary : - UK telephone number
    folder Care and support plan
    0 … 1
    prsb03-dataelement-508link
    This records the decisions reached during conversation between the individual and health and care professional about future plans and also records progress.
    treetree folder Strengths
    0 … *
    prsb03-dataelement-10419link
    Any strengths and assets the person has relating to their goals and hopes about their health and well-being.
    treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-14369link
    The coded value associated with the person's strengths.  Could be derived from the assessment of the person e.g. 300738008 |Able to participate in leisure activities (finding)|

    SNOMED CT : - 1127601000000107 | Healthcare matters simple reference set (foundation metadata concept) |
    treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-14370link
    Any supplementary or personalised information that relates to the person's strengths.Free text
    treetree folder Needs, concerns or problems
    0 … *
    prsb03-dataelement-10414link
    Details of the person needs, concerns or problems
    treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-14371link
    The coded value associated with the person's needs, concerns or problems.SNOMED CT : - ^1127581000000103 |Health issues simple reference set|
    treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-14372link
    Any supplementary or personalised information that relates to the person's needs, concerns and problems.
    Free text 
    treeblank treetree folder Goals and hopes
    0 … *
    prsb03-dataelement-10413link
    The overall goals, hopes, aims or targets that the person has. Including anything that the person wants to achieve that relates to their future health and wellbeing. Each goal may include a description of why it is important to the person. Goals may also be ranked in order of importance or priority to the person.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-14373link
    The coded value associated with the person's goals, aim's and hopes. e.g. 999002111000000103 |Occupational therapy goals simple reference set (foundation metadata concept)|SNOMED CT : - 413350009|Finding with explicit context|: 246090004|Associated finding|=300798006 |Able to participate in sporting activities (finding)|, 408729009|Finding context|=410518001|Goal|
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-14374link
    Any supplementary and personalised information relating to the person's goals, aims and hopes.Free text
    treeblank treeblank treetree draft  Goal importance score
    0 … 1
    prsb03-dataelement-14399link
    Assessment of the person's motivations to achieve this goal, how important the goal is to the person on a scale of 1-10.Numeric scale 1 - 10
    treeblank treeblank treetree folder Actions and activities
    0 … *
    prsb03-dataelement-10408link
    Actions or activities the person or others plan to take to achieve the person's goals and the resources required to do this.

    treeblank treeblank treeblank treetree folder What
    0 … 1
    prsb03-dataelement-10675link
    What the action is and how it is to be carried out?
    treeblank treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-14383link
    The coded value for the action.

    SNOMED CT : - <<71388002 |Procedure| OR <<129125009 |Procedure with explicit context|
    treeblank treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-14384link
    Any supplementary and personalised information for the action.Free text
    treeblank treeblank treeblank treetree folder Who
    0 … 1
    prsb03-dataelement-10676link
    Name and role (e.g. person, carer, GP, OT, etc.) of the person, or a team, carrying out the proposed action, and, if relevant where action should take place.
    treeblank treeblank treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-14393link
    The name of the professional or person carrying out the proposed action.Free text
    treeblank treeblank treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-14394link
    The role of the person providing the service.FHIR values set : - sdsjobrole
    treeblank treeblank treeblank treeblank treetree draft  Team
    0 … 1
    prsb03-dataelement-14395link
    The name of the team.Free text
    treeblank treeblank treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-14396link
    Contact details of the professional (e.g. telephone number, email address etc.).Free text
    treeblank treeblank treeblank treetree draft  When
    0 … 1
    prsb03-dataelement-10677link
    Planned date, time, or interval, as relevantDate and time
    treeblank treeblank treeblank treetree draft  Suggested strategies
    0 … *
    prsb03-dataelement-10678link
    Suggested strategies for potential problems.Free text.
    treeblank treeblank treeblank treetree folder Status
    0 … 1
    prsb03-dataelement-10679link
    The status of the action or activity e.g. in progress, done, refused
    treeblank treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-14385link
    The coded value for the person's activity statusSNOMED CT : - ^999000081000000105 | Care planning action context values simple reference set (foundation metadata concept) |
    treeblank treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-14386link
    Any supplementary or personalised information for the person's activity statusFree text
    treeblank treeblank treeblank treetree draft  Confidence
    0 … 1
    prsb03-dataelement-10680link
    How confident the person feels to carry out the action associated to the goal.Numeric score 1 - 10
    treeblank treeblank treeblank treetree draft  Date last updated
    0 … 1
    prsb03-dataelement-10682link
    Date when action/activity record was last updatedDate and time
    treeblank treeblank treeblank treetree draft  Review date
    0 … 1
    prsb03-dataelement-10683link
    When the action evaluation needs to be reviewed. SNOMED CT tag : - 425268008 | Review of care plan (procedure) |Date and time.
    treeblank treeblank treeblank treetree folder Stage goal
    0 … 1
    prsb03-dataelement-10674link
    Details of the person's stage goals
    treeblank treeblank treeblank treeblank treetree folder Stage goal
    0 … *
    prsb03-dataelement-14284link
    A specific sub-goal that is related to the overall goal as agreed by the person in collaboration with a professional.
    treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-14375link
    The coded expression associated with the person's stage goal.SNOMED CT : - 413350009|Finding with explicit context|: 246090004|Associated finding|=300798006 |Able to participate in sporting activities (finding)|, 408729009|Finding context|=410518001|Goal|
    treeblank treeblank treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-14376link
    Any supplementary or personalised information regarding the person's stage goal.Free text
    treeblank treeblank treeblank treeblank treetree folder Outcome
    0 … 1
    prsb03-dataelement-10681link
    The outcome of the stage goal
    treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-14378link
    The coded value for the person's stage goal outcome.SNOMED CT: - ^1127601000000107 |Healthcare matters simple reference set (foundation metadata concept)| 
    treeblank treeblank treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-14379link
    Any supplementary and personalised information relating to the person's outcome.Free text
    treeblank treeblank treeblank treeblank treetree draft  Goal status
    0 … 1
    prsb03-dataelement-14377link
    The status associated with the person's stage goalSNOMED CT: - ^999000091000000107 | Care planning goal context values simple reference set (foundation metadata concept) |
    treeblank treeblank treetree folder Outcomes
    0 … *
    prsb03-dataelement-10416link
    Outcomes of each of the person’s goals, aims and targets. Includes comments recorded by the person, date and status.
    treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-14380link
    The coded value associated with the person's overall goal outcomeSNOMED CT: - ^1127601000000107 |Healthcare matters simple reference set (foundation metadata concept)| 
    treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-14382link
    Any supplementary and personalised information relating to the person's goal outcome. Free text
    treeblank treeblank treetree draft  Goal status
    0 … 1
    prsb03-dataelement-14400link
    The status associated with the person's overall goal.SNOMED CT: - ^999000091000000107 | Care planning goal context values simple reference set (foundation metadata concept) |
    treetree folder Agreed with person or legitimate representative
    0 … 1
    prsb03-dataelement-10409link
    Indicates whether the plan was discussed and agreed with the person or legitimate representative.
    treeblank treetree draft  Person or legitimate representative
    0 … 1
    prsb03-dataelement-14322link
    Indicates whether the plan was discussed and agreed with the person or legitimate representativePerson or legitimate representative 
    treeblank treetree draft  Person full name
    0 … 1
    prsb03-dataelement-14323link
    The full name of the person in text representation.NHS data dictionary :- Patient full name
    treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-14324link
    The role the professional has in relation to the person.FHIR value set : - sdsjobrole
    treetree folder Care funding source
    0 … 1
    prsb03-dataelement-10410link
    A reference to the funding source and any conditions or limitations associated.
    treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-14391link
    The organisation code of the care funding sourceNHS data dictionary : - organisation data service
    treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-14392link
    Any further information for the person's care funding source e.g. self fundedFree text 
    treetree draft  Date this plan was last updated
    0 … 1
    prsb03-dataelement-10412link
    This is a record of the date that this care and support plan was last updated.Date and time
    treetree draft  Other care planning documents
    0 … *
    prsb03-dataelement-10415link
    Reference other care planning documents, including the type, location and date.

    This may include condition-specific plans, advance care plans, end of life care plan, etc.Free text.
    treetree draft  Planned review date/interval
    0 … 1
    prsb03-dataelement-10417link
    This is the date/interval when this information will next be reviewed. SNOMED CT tag : - 425268008 | Review of care plan (procedure) |Date and time
    treetree folder Responsibility for review
    0 … 1
    prsb03-dataelement-10418link
    This is a record of who has responsibility for arranging review of this information.
    treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-14345link
    The name of the professional with responsibility for the care of the person.Free text
    treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-14346link
    The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker, key worker, care home manager, care coordinator, LA hospital liaison person, care home contact, hospital clinician, Independent Mental Capacity Advocate (IMCA) etcFHIR value set : - SDSjobrole
    treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-14347link
    Contact details of the professional (e.g. telephone number, email address etc.).Free text
    treetree folder Location
    0 … 1
    prsb03-dataelement-12044link
    The location where the care and support plan was prepared.
    treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13665link
    The coded value for locationNHS data dictionary: - Organisation data service
    treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13666link
    Free text field to be used if no coded text available
    treetree folder Performing professional
    0 … 1
    prsb03-dataelement-12027link
    The professional who prepared the care and support plan.
    treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-12028link
    The name of the professional.Free text.
    treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-12029link
    The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
    treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-12030link
    The grade of the professional.Free text
    treeblank treetree draft  Speciality
    0 … 1
    prsb03-dataelement-12031link
    The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
    treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-12032link
    Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
    treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-12033link
    The name of the organisation the professional works for.
    treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-12034link
    Contact details of the professionalNHS data dictionary - UK phone number
    treetree folder Person completing record
    0 … 1
    prsb03-dataelement-12035link
    Details of the person completing the record.
    treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-12036link
    The name of the person completing the record.Free text.
    treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-12037link
    The organisational role of the person completing record.FHIR value set :- SDSjobrole
    treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-12038link
    The grade of the person completing the record.Free text.
    treeblank treetree draft  Specialty
    0 … 1
    prsb03-dataelement-12039link
    The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
    treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-12040link
    The organisation the person completing the record works for. NHS data dictionary : - Organisation data service
    treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-12041link
    Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
    treeblank treetree draft  Date completed
    0 … 1
    prsb03-dataelement-12042link
    The date and time the record was completed.Date and time.
    treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-12043link
    Contact details of the person completing the record.
    NHS data dictionary : - UK telephone number
    folder Contingency/safety plans
    0 … *
    prsb03-dataelement-469link
    These are the things to do and people to contact, should an individual’s health or other circumstances get worse for safety.
    treetree folder Trigger factors
    0 … *
    prsb03-dataelement-10375link
    Signs to watch out for that may indicate a significant change in health or other circumstances e.g. feeling agitated
    treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-14389link
    The trigger that leads to instigation of a significant change in health or other circumstances.
    SNOMED CT: - ^1127581000000103 | Health issues simple reference set (foundation metadata concept) |
    treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-14390link
    Any free text associated with the person's trigger factorFree text
    treetree folder Contingency plan name
    0 … 1
    prsb03-dataelement-10371link
    When the action evaluation needs to be reviewed. 
    treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-14387link
    The coded value for the type of care planSNOMED CT: - 999001471000000108 | Care plan type simple reference set (foundation metadata concept) |
    treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-14388link
    Free text if no coded value is available.Free text
    treetree folder What should happen
    0 … *
    prsb03-dataelement-10376link
    Guidance on specific actions or interventions that may be required or should be avoided in specific situations. This may include circumstances where action needs to be taken if a carer is unable to care for the person. A statement of suggested actions. Usually expressed as: in the event of X do Y.
    treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-14403link
    The coded value for what should happen SNOMED CT : - <<71388002 |Procedure| OR <<129125009 |Procedure with explicit context|
    treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-14404link
    Any supplementary or personalised information regarding what should happen Free text
    treetree folder Who should be contacted
    0 … *
    prsb03-dataelement-10377link
    Who should be contacted in the event of significant problems or deterioration in health or wellbeing. e.g. name, role and contact details.
    treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-14405link
    The name of the professional with responsibility for the care of the person.Free text
    treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-14406link
    The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker, key worker, care home manager, care coordinator, LA hospital liaison person, care home contact, hospital clinician, Independent Mental Capacity Advocate (IMCA) etcFHIR value set : - SDSjobrole
    treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-14407link
    Contact details of the personal contact (e.g. telephone number, email address etc.)Free Text
    treetree folder Agreed with person or legitimate representative
    0 … 1
    prsb03-dataelement-10369link
    Indicates whether the plan was discussed and agreed with the person or legitimate representative.
    treeblank treetree draft  Person or legitimate representative
    0 … 1
    prsb03-dataelement-14339link
    Indicates whether the plan was discussed and agreed with the person or legitimate representativePerson or legitimate representative 
    treeblank treetree draft  Person full name
    0 … 1
    prsb03-dataelement-14340link
    The full name of the person in text representation.NHS data dictionary :- Patient full name
    treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-14341link
    The role the professional has in relation to the person.FHIR value set : - sdsjobrole
    treetree draft  Date this plan was last updated
    0 … 1
    prsb03-dataelement-10372link
    The date that this contingency plan was last updated.Date and time
    treetree draft  Planned review date/interval
    0 … 1
    prsb03-dataelement-10373link
    This is the date/interval when this contingency plan will next be reviewed. SNOMED CT tag : - 425268008 | Review of care plan (procedure) |Date and time
    treetree folder Responsibility for review
    0 … 1
    prsb03-dataelement-10374link
    This is who has responsibility for arranging review of this information.
    treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-14342link
    The name of the professional with responsibility for the care of the person.Free text
    treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-14343link
    The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker, key worker, care home manager, care coordinator, LA hospital liaison person, care home contact, hospital clinician, Independent Mental Capacity Advocate (IMCA) etcFHIR value set : - SDSjobrole
    treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-14344link
    Contact details of the professional (e.g. telephone number, email address etc.).Free text
    treetree folder Coping strategies
    0 … *
    prsb03-dataelement-13850link
    Details of coping strategies used
    treeblank treetree draft  Coping strategy
    0 … 1
    prsb03-dataelement-13851link
    The coping strategies are defined as thoughts and behaviours that people use to manage the internal and external demands of situations that are appraised as stressful. This should also include a record of any tools used to carry out the coping strategy.Free text
    treeblank treetree draft  Start date
    0 … 1
    prsb03-dataelement-13852link
    The date when the coping strategy startedDate and time
    treeblank treetree draft  End date
    0 … 1
    prsb03-dataelement-13853link
    The date when the coping strategy endedDate and time
    treetree folder Relapse indicators / early warning signs
    0 … *
    prsb03-dataelement-13854link
    Details of the relapse indicators for the person. These may also be called 'early warning signs'
    treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-14401link
    The coded value for relapse indicators/early warning signsSNOMED CT : - ^1127601000000107 | Healthcare matters simple reference set (foundation metadata concept) |
    treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-14402link
    Any supplementary or personalised information regarding the relapse indicators/early warning signsFree text
    treetree folder Advance statement
    0 … 1
    prsb03-dataelement-10777link
    Written requests and preferences made by a person with capacity conveying their wishes, beliefs and values for their future care should they lose capacity.
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-12267link
    The date when the advanced statements was made.Date and time
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-12268link
    The location where the advanced statement was made.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13698link
    The coded value for locationNHS data dictionary: - Organisation data service
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13699link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Advance statement
    0 … 1
    prsb03-dataelement-13695link
    Does the person have an advance statement.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13696link
    The coded value for advance statementSNOMED CT: - 816281000000101 | Has advance statement (Mental Capacity Act 2005) (finding) |
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13697link
    Free text field to be used if no code is availableFree text
    treeblank treetree draft  Location of document
    0 … 1
    prsb03-dataelement-13760link
    The location of where the advanced statement is held.Free text or URL
    treeblank treetree folder Performing professional
    0 … 1
    prsb03-dataelement-12269link
    The professional who made the advance statement.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-12270link
    The name of the professional.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-12271link
    The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-12272link
    The grade of the professional.Free text
    treeblank treeblank treetree draft  Speciality
    0 … 1
    prsb03-dataelement-12273link
    The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-12274link
    Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-12275link
    The name of the organisation the professional works for.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-12276link
    Contact details of the professionalNHS data dictionary - UK phone number
    treeblank treetree folder Person completing record
    0 … 1
    prsb03-dataelement-12277link
    Details of the person completing the record.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-12278link
    The name of the person completing the record.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-12279link
    The organisational role of the person completing record.FHIR value set :- SDSjobrole
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-12280link
    The grade of the person completing the record.Free text.
    treeblank treeblank treetree draft  Specialty
    0 … 1
    prsb03-dataelement-12281link
    The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-12282link
    The organisation the person completing the record works for. NHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-12283link
    Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
    treeblank treeblank treetree draft  Date completed
    0 … 1
    prsb03-dataelement-12284link
    The date and time the record was completed.Date and time.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-12285link
    Contact details of the person completing the record.
    NHS data dictionary : - UK telephone number
    treetree draft  Anticipatory medicines/equipment
    0 … *
    prsb03-dataelement-10370link
    Medicines or equipment available that may be required in specific situations and their location. A statement regarding the availability or location of the anticipatory medicines/equipment. SNOMED CT Tag : - 871021000000106 | Prescription of palliative care anticipatory medication (procedure) |Free text
    treetree folder Location
    0 … 1
    prsb03-dataelement-12079link
    The location where the contingency plan was prepared.
    treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13667link
    The coded value for locationNHS data dictionary : - Organisation data service
    treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13668link
    Free text field to be used if no code is availableFree text
    treetree folder Performing professional
    0 … 1
    prsb03-dataelement-12045link
    The professional who prepared the contingency plans.
    treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-12046link
    The name of the professional.Free text.
    treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-12047link
    The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
    treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-12048link
    The grade of the professional.Free text
    treeblank treetree draft  Speciality
    0 … 1
    prsb03-dataelement-12049link
    The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
    treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-12050link
    Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
    treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-12051link
    The name of the organisation the professional works for.
    treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-12052link
    Contact details of the professionalNHS data dictionary - UK phone number
    treetree folder Person completing record
    0 … 1
    prsb03-dataelement-12053link
    Details of the person completing the record.
    treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-12054link
    The name of the person completing the record.Free text.
    treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-12055link
    The organisational role of the person completing record.FHIR value set :- SDSjobrole
    treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-12056link
    The grade of the person completing the record.Free text.
    treeblank treetree draft  Specialty
    0 … 1
    prsb03-dataelement-12057link
    The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
    treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-12058link
    The organisation the person completing the record works for. NHS data dictionary : - Organisation data service
    treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-12059link
    Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
    treeblank treetree draft  Date completed
    0 … 1
    prsb03-dataelement-12060link
    The date and time the record was completed.Date and time.
    treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-12061link
    Contact details of the person completing the record.
    NHS data dictionary : - UK telephone number
    folder Additional support plans
    0 … *
    prsb03-dataelement-502link
    Additional support plans
    treetree folder Additional support plan name
    0 … 1
    prsb03-dataelement-10402link
    The name of the particular additional supporting plan, e.g. dieticians plan, wound management plan, discharge management plan and behaviour support plan.
    treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-14397link
    The coded value for the type of care planSNOMED CT: - 999001471000000108 | Care plan type simple reference set (foundation metadata concept) |
    treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-14398link
    Free text if no coded value is availableFree text
    treetree draft  Additional support plan content
    0 … 1
    prsb03-dataelement-10403link
    This is the content of any additional care and support plan which the person and/or care professional consider should be shared with others providing care and support. May be structured in different ways, e.g. tables, diagrams, images. This is the content of any additional care and support plan which the individual and/or care professional consider should be shared with others providing care and support. It should be structured as recommended for the care and support plan and if contains additional detail, it may be referenced here.Free text
    treetree draft  Planned review date/interval
    0 … 1
    prsb03-dataelement-10405link
    This is the date/interval when this information will next be reviewed. SNOMED CT tag : - 425268008 | Review of care plan (procedure) |Date and time
    treetree folder Responsibility for review
    0 … 1
    prsb03-dataelement-10406link
    This is a record of who has responsibility for arranging review of this information. Should include their name, role and contact details.
    treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-14348link
    The name of the professional with responsibility for the care of the person.Free text
    treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-14349link
    The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker, key worker, care home manager, care coordinator, LA hospital liaison person, care home contact, hospital clinician, Independent Mental Capacity Advocate (IMCA) etcFHIR value set : - SDSjobrole
    treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-14350link
    Contact details of the professional (e.g. telephone number, email address etc.).Free text
    treetree draft  Date this plan was last updated
    0 … 1
    prsb03-dataelement-10407link
    This is a record of the date that this information was last updated.Date and time
    treetree folder Location
    0 … 1
    prsb03-dataelement-12080link
    The location where the additional support plan was prepared.ODS code or free text
    treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13722link
    The coded value for locationNHS data dictionary:- Organisation data service
    treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13723link
    Free text field to be used if no code is availableFree text
    treetree folder Performing professional
    0 … 1
    prsb03-dataelement-12062link
    The professional who prepared the additional support plan.
    treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-12063link
    The name of the professional.Free text.
    treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-12064link
    The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
    treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-12065link
    The grade of the professional.Free text
    treeblank treetree draft  Speciality
    0 … 1
    prsb03-dataelement-12066link
    The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
    treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-12067link
    Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
    treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-12068link
    The name of the organisation the professional works for.
    treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-12069link
    Contact details of the professionalNHS data dictionary - UK phone number
    treetree folder Person completing record
    0 … 1
    prsb03-dataelement-12070link
    Details of the person completing the record.
    treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-12071link
    The name of the person completing the record.Free text.
    treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-12072link
    The organisational role of the person completing record.FHIR value set :- SDSjobrole
    treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-12073link
    The grade of the person completing the record.Free text.
    treeblank treetree draft  Specialty
    0 … 1
    prsb03-dataelement-12074link
    The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
    treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-12075link
    The organisation the person completing the record works for. NHS data dictionary : - Organisation data service
    treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-12076link
    Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
    treeblank treetree draft  Date completed
    0 … 1
    prsb03-dataelement-12077link
    The date and time the record was completed.Date and time.
    treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-12078link
    Contact details of the person completing the record.
    NHS data dictionary : - UK telephone number
    folder End of life care
    0 … 1
    prsb03-dataelement-10743link
    Information relating to end of life care.

    N.B. This is not an end of life care plan but contains information that would be found in an end of life care plan.
    treetree folder Cardio-pulmonary resuscitation (CPR) decision
    0 … 1
    prsb03-dataelement-10771link
    Whether a decision has been made, the decision, who made the decision, the date of decision, date for review and location of documentation. Where the person or their family member/carer have not been informed of the clinical decision please state the reason why.
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-12210link
    The date when the cardio-pulmonary resuscitation decision was made.Date and time.
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-12211link
    The location where the cardio-pulmonary resuscitation decision was made.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13689link
    The coded value for locationNHS data dictionary: - Organisation data service
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13690link
    Free text field to be used if no coded text available
    treeblank treetree folder Cardio-pulmonary resuscitation (CPR) decision
    0 … 1
    prsb03-dataelement-13686link
    The cardio-pulmonary resuscitation (CPR) decision.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13687link
    The coded value for CPR decision or DNACPRSNOMED CT: - 450475007 | For cardiopulmonary resuscitation (finding) |, 450476008 | Not for cardiopulmonary resuscitation (finding) |
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13688link
    Free text field to be used if no code is availableFree text
    treeblank treetree draft  Date for review
    0 … 1
    prsb03-dataelement-13705link
    The date for review of CPR decision.Date and time
    treeblank treetree draft  Location of document
    0 … 1
    prsb03-dataelement-13706link
    The location of the CPR decision documentFree text or URL
    treeblank treetree folder Performing professional
    0 … 1
    prsb03-dataelement-12212link
    The professional who made the cardio-pulmonary resuscitation decision.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-12213link
    The name of the professional.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-12214link
    The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-12215link
    The grade of the professional.Free text
    treeblank treeblank treetree draft  Speciality
    0 … 1
    prsb03-dataelement-12216link
    The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-12217link
    Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-12218link
    The name of the organisation the professional works for.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-12219link
    Contact details of the professionalNHS data dictionary - UK phone number
    treeblank treetree folder Person completing record
    0 … 1
    prsb03-dataelement-12220link
    Details of the person completing the record.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-12221link
    The name of the person completing the record.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-12222link
    The organisational role of the person completing record.FHIR value set :- SDSjobrole
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-12223link
    The grade of the person completing the record.Free text.
    treeblank treeblank treetree draft  Specialty
    0 … 1
    prsb03-dataelement-12224link
    The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-12225link
    The organisation the person completing the record works for. NHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-12226link
    Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
    treeblank treeblank treetree draft  Date completed
    0 … 1
    prsb03-dataelement-12227link
    The date and time the record was completed.Date and time.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-12228link
    Contact details of the person completing the record.
    NHS data dictionary : - UK telephone number
    treetree folder Estimated prognosis
    0 … 1
    prsb03-dataelement-10745link
    Details of the persons estimated prognosis
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-12229link
    The date when the estimated prognosis was made.Date and time
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-12230link
    The location where the estimated prognosis was made.ODS code or free text
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13703link
    The coded value for locationNHS data dictionary: - Organisation data service
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13704link
    Free text field to be used if no coded text available
    treeblank treetree draft  Estimated prognosis
    0 … 1
    prsb03-dataelement-13691link
    Where a person is terminally ill this is a clinical judgment indicating the anticipated period of time until death e.g. last days, weeks, months or year of life.Free text
    treeblank treetree folder Performing professional
    0 … 1
    prsb03-dataelement-12231link
    The professional who made the estimated prognosis.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-12232link
    The name of the professional.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-12233link
    The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-12234link
    The grade of the professional.Free text
    treeblank treeblank treetree draft  Speciality
    0 … 1
    prsb03-dataelement-12235link
    The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-12236link
    Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-12237link
    The name of the organisation the professional works for.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-12238link
    Contact details of the professionalNHS data dictionary - UK phone number
    treeblank treetree folder Person completing record
    0 … 1
    prsb03-dataelement-12239link
    Details of the person completing the record.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-12240link
    The name of the person completing the record.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-12241link
    The organisational role of the person completing record.FHIR value set :- SDSjobrole
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-12242link
    The grade of the person completing the record.Free text.
    treeblank treeblank treetree draft  Specialty
    0 … 1
    prsb03-dataelement-12243link
    The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-12244link
    The organisation the person completing the record works for. NHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-12245link
    Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
    treeblank treeblank treetree draft  Date completed
    0 … 1
    prsb03-dataelement-12246link
    The date and time the record was completed.Date and time.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-12247link
    Contact details of the person completing the record.
    NHS data dictionary : - UK telephone number
    treetree folder Awareness of prognosis
    0 … 1
    prsb03-dataelement-10775link
    Details of the persons awareness of prognosis
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-12248link
    The date when the assessment of the level of awareness of the prognosis was made.Date and time
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-12249link
    The location where the assessment of the level of awareness of the prognosis was made.ODS code and free text
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13693link
    The coded value for locationNHS data dictionary: - Organisation data service
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13694link
    Free text field to be used if no code is availableFree text
    treeblank treetree draft  Awareness of prognosis
    0 … 1
    prsb03-dataelement-13692link
    Description of the level of awareness the person and or their carer/family has regarding their estimated prognosis.Free text
    treeblank treetree folder Performing professional
    0 … 1
    prsb03-dataelement-12250link
    The professional who made the assessment of the level of awareness of the prognosis.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-12251link
    The name of the professional.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-12252link
    The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-12253link
    The grade of the professional.Free text
    treeblank treeblank treetree draft  Speciality
    0 … 1
    prsb03-dataelement-12254link
    The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-12255link
    Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-12256link
    The name of the organisation the professional works for.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-12257link
    Contact details of the professionalNHS data dictionary - UK phone number
    treeblank treetree folder Person completing record
    0 … 1
    prsb03-dataelement-12258link
    Details of the person completing the record.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-12259link
    The name of the person completing the record.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-12260link
    The organisational role of the person completing record.FHIR value set :- SDSjobrole
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-12261link
    The grade of the person completing the record.Free text.
    treeblank treeblank treetree draft  Specialty
    0 … 1
    prsb03-dataelement-12262link
    The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-12263link
    The organisation the person completing the record works for. NHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-12264link
    Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
    treeblank treeblank treetree draft  Date completed
    0 … 1
    prsb03-dataelement-12265link
    The date and time the record was completed.Date and time.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-12266link
    Contact details of the person completing the record.
    NHS data dictionary : - UK telephone number
    treetree draft  Priorities of care
    0 … *
    prsb03-dataelement-10201link
    The priorities agreed between the person and their health/care team, where the person has capacity: To get better; please consider all treatment to prolong life. To achieve a balance between getting better and ensuring good quality of life; please consider selected treatments. Comfort; please consider all treatments aimed at symptom control.Free text
    treetree folder Anticipatory actions
    0 … *
    prsb03-dataelement-10786link
    Details of the person's anticipatory actions
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-12286link
    The date when the anticipatory actions were identified.Date and time
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-12287link
    The location where the anticipatory actions were identified.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13701link
    The coded value for locationNHS data dictionary: - Organisation data service
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13702link
    Free text field to be used if no coded text available
    treeblank treetree draft  Anticipatory actions
    0 … 1
    prsb03-dataelement-13700link
    Guidance on specific interventions or actions that may be required or should be avoided in specific situations. A statement of anticipatory actions. Usually expressed as: in the event of X do Y.Free text
    treeblank treetree folder Performing professional
    0 … 1
    prsb03-dataelement-12288link
    The professional who identified the anticipatory actions.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-12289link
    The name of the professional.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-12290link
    The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-12291link
    The grade of the professional.Free text
    treeblank treeblank treetree draft  Speciality
    0 … 1
    prsb03-dataelement-12292link
    The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-12293link
    Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-12294link
    The name of the organisation the professional works for.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-12295link
    Contact details of the professionalNHS data dictionary - UK phone number
    treeblank treetree folder Person completing record
    0 … 1
    prsb03-dataelement-12296link
    Details of the person completing the record.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-12297link
    The name of the person completing the record.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-12298link
    The organisational role of the person completing record.FHIR value set :- SDSjobrole
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-12299link
    The grade of the person completing the record.Free text.
    treeblank treeblank treetree draft  Specialty
    0 … 1
    prsb03-dataelement-12300link
    The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-12301link
    The organisation the person completing the record works for. NHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-12302link
    Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
    treeblank treeblank treetree draft  Date completed
    0 … 1
    prsb03-dataelement-12303link
    The date and time the record was completed.Date and time.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-12304link
    Contact details of the person completing the record.
    NHS data dictionary : - UK telephone number
    treetree folder Anticipatory medicines/equipment
    0 … *
    prsb03-dataelement-10785link
    Details of the persons availability or location regarding their anticipatory medicines/equipment.
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-12305link
    The date when the statement regarding anticipatory medicines/equipment was made.Date and time
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-12306link
    The location where the statement regarding anticipatory medicines/equipment was made.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13708link
    The coded value for locationNHS data dictionary: - Organisation data service
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13709link
    Free text field to be used if no coded text available
    treeblank treetree draft  Anticipatory medicines/equipment
    0 … 1
    prsb03-dataelement-13707link
    A statement regarding the availability or location of the anticipatory medicines/equipment.Free text
    treeblank treetree folder Performing professional
    0 … 1
    prsb03-dataelement-12307link
    The professional who made the statement regarding anticipatory medicines/equipment was made.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-12308link
    The name of the professional.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-12309link
    The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-12310link
    The grade of the professional.Free text
    treeblank treeblank treetree draft  Speciality
    0 … 1
    prsb03-dataelement-12311link
    The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-12312link
    Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-12313link
    The name of the organisation the professional works for.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-12314link
    Contact details of the professionalNHS data dictionary - UK phone number
    treeblank treetree folder Person completing record
    0 … 1
    prsb03-dataelement-12315link
    Details of the person completing the record.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-12316link
    The name of the person completing the record.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-12317link
    The organisational role of the person completing record.FHIR value set :- SDSjobrole
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-12318link
    The grade of the person completing the record.Free text.
    treeblank treeblank treetree draft  Specialty
    0 … 1
    prsb03-dataelement-12319link
    The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-12320link
    The organisation the person completing the record works for. NHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-12321link
    Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
    treeblank treeblank treetree draft  Date completed
    0 … 1
    prsb03-dataelement-12322link
    The date and time the record was completed.Date and time.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-12323link
    Contact details of the person completing the record.
    NHS data dictionary : - UK telephone number
    treetree folder Preferred place of death
    0 … 1
    prsb03-dataelement-10780link
    Details of the person's preferred place of death
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-12324link
    The date when the preferred place of death was identified.Date and time
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-12325link
    The location where the preferred place of death was identified.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13713link
    The coded value for locationNHS data dictionary: - Organisation data service
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13714link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Preferred place of death 1st
    0 … 1
    prsb03-dataelement-13710link
    The preferences that a person has identified as their preferred place to die.
    treeblank treeblank treetree draft  Name of the place
    0 … 1
    prsb03-dataelement-13711link
    The name of the preferred place of deathFree text
    treeblank treeblank treetree draft  Type of place
    0 … 1
    prsb03-dataelement-13712link
    The type of preferred place of deathSCC11580 code : - 10: Hospital (Acute/Community/Other)20: Private residence21: Patient's own home22: Other private residence (eg relatives home, carers home)30: Hospice (inpatient specialist palliative care)40: Care Home50: Other (free text eg secure and detained settings)517111000000103, Preferred place of death: patient unable to express preference 517131000000106, Preferred place of death: discussion not appropriate766391000000108, Preferred place of death: patient declined discussion517161000000101, Preferred place of death: patient undecided
    treeblank treetree folder Preferred place of death 2nd
    0 … 1
    prsb03-dataelement-13716link
    The preferences that a person has identified as their preferred place to die.
    treeblank treeblank treetree draft  Name of the place
    0 … 1
    prsb03-dataelement-13717link
    The name of the preferred place of deathFree text
    treeblank treeblank treetree draft  Type of place
    0 … 1
    prsb03-dataelement-13718link
    The type of preferred place of deathSCC11580 code : - 10: Hospital (Acute/Community/Other)20: Private residence21: Patient's own home22: Other private residence (eg relatives home, carers home)30: Hospice (inpatient specialist palliative care)40: Care Home50: Other (free text eg secure and detained settings)517111000000103, Preferred place of death: patient unable to express preference 517131000000106, Preferred place of death: discussion not appropriate766391000000108, Preferred place of death: patient declined discussion517161000000101, Preferred place of death: patient undecided
    treeblank treetree folder Performing professional
    0 … 1
    prsb03-dataelement-12326link
    The professional who identified the preferred place of death.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-12327link
    The name of the professional.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-12328link
    The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-12329link
    The grade of the professional.Free text
    treeblank treeblank treetree draft  Speciality
    0 … 1
    prsb03-dataelement-12330link
    The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-12331link
    Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-12332link
    The name of the organisation the professional works for.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-12333link
    Contact details of the professionalNHS data dictionary - UK phone number
    treeblank treetree folder Person completing record
    0 … 1
    prsb03-dataelement-12334link
    Details of the person completing the record.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-12335link
    The name of the person completing the record.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-12336link
    The organisational role of the person completing record.FHIR value set :- SDSjobrole
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-12337link
    The grade of the person completing the record.Free text.
    treeblank treeblank treetree draft  Specialty
    0 … 1
    prsb03-dataelement-12338link
    The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-12339link
    The organisation the person completing the record works for. NHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-12340link
    Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
    treeblank treeblank treetree draft  Date completed
    0 … 1
    prsb03-dataelement-12341link
    The date and time the record was completed.Date and time.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-12342link
    Contact details of the person completing the record.
    NHS data dictionary : - UK telephone number
    treetree folder Preferred place of care
    0 … 1
    prsb03-dataelement-10781link
    Details of the persons preferred place of care
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-12362link
    The date when the preferred place of care was identified.Date and time
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-12363link
    The location where the preferred place of care was identified.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13720link
    The coded value for locationNHS data dictionary: - Organisation data service
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13721link
    Free text field to be used if no code is availableFree text
    treeblank treetree draft  Preferred place of care
    0 … 1
    prsb03-dataelement-13719link
    The preferences that the person has identified as their preferred place to receive care.Free text
    treeblank treetree folder Performing professional
    0 … 1
    prsb03-dataelement-12364link
    The professional who identified the preferred place of care.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-12365link
    The name of the professional.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-12366link
    The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-12367link
    The grade of the professional.Free text
    treeblank treeblank treetree draft  Speciality
    0 … 1
    prsb03-dataelement-12368link
    The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-12369link
    Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-12370link
    The name of the organisation the professional works for.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-12371link
    Contact details of the professionalNHS data dictionary - UK phone number
    treeblank treetree folder Person completing record
    0 … 1
    prsb03-dataelement-12372link
    Details of the person completing the record.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-12373link
    The name of the person completing the record.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-12374link
    The organisational role of the person completing record.FHIR value set :- SDSjobrole
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-12375link
    The grade of the person completing the record.Free text.
    treeblank treeblank treetree draft  Specialty
    0 … 1
    prsb03-dataelement-12376link
    The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-12377link
    The organisation the person completing the record works for. NHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-12378link
    Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
    treeblank treeblank treetree draft  Date completed
    0 … 1
    prsb03-dataelement-12379link
    The date and time the record was completed.Date and time.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-12380link
    Contact details of the person completing the record.
    NHS data dictionary : - UK telephone number
    folder Documents (including correspondence, audio and images)
    0 … 1
    prsb03-dataelement-10820link
    Details about documents related to the person.
    treetree folder Documents
    0 … *
    prsb03-dataelement-11259link
    This is the documents record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-10943link
    The date and time the document was created.Date and time
    treeblank treetree folder Performing professional
    0 … 1
    prsb03-dataelement-12422link
    The professional who authored the document.Free text.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-12423link
    The name of the professional.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-12424link
    The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-12425link
    The grade of the professional.Free text
    treeblank treeblank treetree draft  Speciality
    0 … 1
    prsb03-dataelement-12426link
    The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-12427link
    Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-12428link
    The name of the organisation the professional works for.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-12429link
    Contact details of the professionalNHS data dictionary - UK phone number
    treeblank treetree draft  Documentation location
    0 … 1
    prsb03-dataelement-10946link
    The location of the documentFree text or URL
    treeblank treetree draft  Confidentiality
    0 … 1
    prsb03-dataelement-10942link
    The code specifying the level of confidentiality of the document. FHIR value set : - Confidentiality
    treeblank treetree draft  Class
    0 … 1
    prsb03-dataelement-10940link
    The document type e.g. report, summary, images, treatment plan, patient preferences, workflowFree text.
    treeblank treetree draft  Document title
    0 … 1
    prsb03-dataelement-10944link
    The title of the document.Free text
    treeblank treetree draft  Document name
    0 … 1
    prsb03-dataelement-10945link
    The name of the document. This should align to the PRSB document naming standard. Where the document is a KOS document this field (designated typeCode) is used to carry the DICOM Imaging procedure: This attribute shall be populated by the XDS-I Imaging Document Source from a code in the Procedure Code Sequence (0008,1032) of the performed procedure with which the document is associated. Values may be found in a suitable DICOM browserSNOMED CT: - As per the https://theprsb.org/wp-content/uploads/2018/11/Clinical-document-indexing-standards_NHS-Scotland.pdf
    treeblank treetree draft  Document MIME type
    0 … 1
    prsb03-dataelement-10949link
    MIME type of the document e.g. application, pdf, audio, jpegFree text
    treeblank treetree folder Person completing record
    0 … 1
    prsb03-dataelement-12430link
    Details of the person completing the record.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-12431link
    The name of the person completing the record.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-12432link
    The organisational role of the person completing record.FHIR value set :- SDSjobrole
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-12433link
    The grade of the person completing the record.Free text.
    treeblank treeblank treetree draft  Specialty
    0 … 1
    prsb03-dataelement-12434link
    The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-12435link
    The organisation the person completing the record works for. NHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-12436link
    Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
    treeblank treeblank treetree draft  Date completed
    0 … 1
    prsb03-dataelement-12437link
    The date and time the record was completed.Date and time.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-12438link
    Contact details of the person completing the record.
    NHS data dictionary : - UK telephone number
    treeblank treetree folder Service
    0 … 1
    prsb03-dataelement-11163link
    The high level imaging speciality code e.g. (R-3027B, SRT, “Radiology”)SNOMED CT or free text 999000381000000107 |Correspondence care setting type simple reference set (foundation metadata concept)|
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13749link
    The coded value for serviceSNOMED CT :- 1127531000000102 |Services simple reference set (foundation metadata concept)|
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13750link
    Free text field to be used if no code is availableFree text
    treeblank treetree draft  Comments
    0 … 1
    prsb03-dataelement-10941link
    Comments associated with the document.Free text
    treeblank treetree folder Additional information required for images.
    0 … 1
    prsb03-dataelement-12449link
    Additional information required for images.
    treeblank treeblank treetree draft  Image procedure
    0 … 1
    prsb03-dataelement-12450link
    The procedure used to capture the imageFree text Using DICOM code set https://dicom.innolitics.com/ciods
    treeblank treeblank treetree draft  Image procedure date
    0 … 1
    prsb03-dataelement-12451link
    The date and time the image procedure was performed.Date and time
    treeblank treeblank treetree folder Images
    0 … 1
    prsb03-dataelement-11158link
    treeblank treeblank treeblank treetree draft  Image capture date
    0 … 1
    prsb03-dataelement-11159link
    The date and time when the image was captured.Date and time
    treeblank treeblank treeblank treetree draft  Image ID
    0 … 1
    prsb03-dataelement-12460link
    A unique image identifier generated by the system.Free text
    treeblank treeblank treeblank treetree draft  Image location
    0 … 1
    prsb03-dataelement-12461link
    The URL for the imageFree text
    treeblank treeblank treetree draft  Format code
    0 … 1
    prsb03-dataelement-11161link
    The format code of the document which provides information on how to display the document.Free text
    treeblank treeblank treetree draft  Event code list
    0 … 1
    prsb03-dataelement-11160link
    The type of image (acquisition modality) and the anatomical site imaged.DICOM code
    treeblank treeblank treetree draft  Comments
    0 … 1
    prsb03-dataelement-12471link
    Comments associated with the imagingFree text
    cancelled rotate CIS (rationalised)
    prsb03-transaction-230link
    Version / effective date 0.1 - 2021‑02‑02 15:48:07    
    Actor
    stationary (organization) Shared care record
    Associations
    Contained concepts
    Concept Card/Conf Id
    folder Person demographics
    1 … 1 Mandatory
    prsb03-dataelement-10868link
    The person's details and contact information.
    treetree folder Person name
    1 … 1 Mandatory
    prsb03-dataelement-10869link
    Details of the person's name
    treeblank treetree draft  Person first name
    1 … * Mandatory
    prsb03-dataelement-13799link
    The first name(s) of the person. This includes middle names.NHS data dictionary :- Person given name
    treeblank treetree draft  Person family name
    1 … * Mandatory
    prsb03-dataelement-13800link
    The family name or surname of the personNHS data dictionary : - Person family name
    treeblank treetree draft  Person preferred name
    0 … 1
    prsb03-dataelement-10870link
    The name by which a person wishes to be addressed. The preferred name volunteered by the person or a preferred name given by PDS that the person has asked to be called by.NHS data dictionary: - Person full name
    treeblank treetree draft  Title
    0 … 1
    prsb03-dataelement-13089link
    Person's titleNHS data dictionary: - Person title
    treeblank treetree draft  Person name suffix
    0 … *
    prsb03-dataelement-13798link
    A textual suffix that may be added to the end of a PERSON's name, for example, OBE, MBE, BSc, JP, GMNHS data dictionary: - Person suffix
    treeblank treetree draft  Person full name
    0 … 1
    prsb03-dataelement-13801link
    The full name of the person in text representation.NHS data dictionary :- Patient full name
    treetree draft  Date of birth
    1 … 1 Mandatory
    prsb03-dataelement-10871link
    The date of birth of the person.NHS data dictionary:- Person birth date
    treetree draft  Gender
    0 … 1
    prsb03-dataelement-10872link
    The person's stated gender.NHS data dictionary :- Person stated gender code
    treetree draft  Ethnicity
    0 … 1
    prsb03-dataelement-10874link
    The ethnicity of the person as specified by the person.NHS data dictionary :- Ethnic category
    treetree draft  Religion
    0 … 1
    prsb03-dataelement-10876link
    The religious affiliation as specified by the person. SNOMED_CT:- Religion
    treetree draft  Sex
    0 … 1
    prsb03-dataelement-10877link
    The person’s phenotypic sex. Determines how the person will be treated clinically.NHS data dictionary: - person phenotypic sex
    treetree draft  NHS number
    0 … 1
    prsb03-dataelement-10879link
    The unique identifier for a person within the NHS in England and Wales.NHS data dictionary:- NHS number
    treetree draft  NHS number status indicator
    0 … 1
    prsb03-dataelement-13297link
    Provides an indication of the reliability of an NHS Number.NHS data dictionary :- NHS number status indicator
    treetree draft  Other identifier
    0 … *
    prsb03-dataelement-10880link
    Country specific or local identifier, e.g. Community Health Index (CHI) in Scotland. NHS data dictionary: - Local patient identifier(extended), Health and care number (NI only), Community health index number (Scotland only)
    treetree folder Person's address
    1 … * Mandatory
    prsb03-dataelement-10881link
    Person’s usual place of residence, and where relevant temporary and correspondence addresses.
    treeblank treetree draft  Address line 1
    1 … 1 Mandatory
    prsb03-dataelement-13082link
    Person's first line of address. NHS data dictionary :-  Address line 1
    treeblank treetree draft  Address line 2
    0 … 1
    prsb03-dataelement-13083link
    Person's second line of address. NHS data dictionary :- Address line 2
    treeblank treetree draft  Address line 3
    0 … 1
    prsb03-dataelement-13084link
    Person's third line of address. NHS data dictionary : - Address line 3
    treeblank treetree draft  Address line 4
    0 … 1
    prsb03-dataelement-13085link
    Person's fourth line of address. NHS data dictionary : - Address line 4
    treeblank treetree draft  Address line 5
    0 … 1
    prsb03-dataelement-13086link
    Person's fifth line of address.NHS data dictionary : - Address line 5
    treeblank treetree draft  Postcode
    0 … 1
    prsb03-dataelement-13087link
    The person's postcode.NHS data dictionary :- Postcode of usual address
    treeblank treetree draft  Address type
    0 … 1
    prsb03-dataelement-13221link
    The type of address e.g. Main address, Temp addressNHS data dictionary : - Address association type
    treetree folder Person's contact details
    0 … 1
    prsb03-dataelement-13804link
    Details of the person's contact information.
    treeblank treetree draft  Preferred contact method
    0 … 1
    prsb03-dataelement-10886link
    Preferred contact method, e.g. email, letter, phone, text message etc.NHS data dictionary :- Communication contact method
    treeblank treetree folder Person's telephone number details
    0 … *
    prsb03-dataelement-10883link
    The person's telephone number details
    treeblank treeblank treetree draft  Person's telephone number
    0 … 1
    prsb03-dataelement-13808link
    The person's telephone numberNHS data dictionary : - UK telephone number
    treeblank treeblank treetree draft  Person's telephone number type
    0 … 1
    prsb03-dataelement-13805link
    The contact type e.g. home, mobileFHIR value set: - Contact point use
    treeblank treeblank treetree draft  Preference of telephone number
    0 … 1
    prsb03-dataelement-13809link
    The preferred order of use for the telephone numberPreference of use 1-5, 1 being the highest.
    treeblank treetree folder Person's email address details
    0 … *
    prsb03-dataelement-13807link
    Details of the person's email address
    treeblank treeblank treetree draft  Person's email address
    0 … 1
    prsb03-dataelement-10882link
    Email address of the person.NHS data dictionary :- Contact email address
    treeblank treeblank treetree draft  Person's email address type
    0 … 1
    prsb03-dataelement-13811link
    The type of email address, home, workFHIR value set: - Contact point use
    treeblank treeblank treetree draft  Preference of email address
    0 … 1
    prsb03-dataelement-13810link
    The preferred order of use of email addressPreference of use 1-5, 1 being the highest.
    treeblank treetree draft  Other contact information
    0 … 1
    prsb03-dataelement-13806link
    Contact details via fax, sms, urlNHS data dictionary:- Communication contact string
    treetree draft  Photograph
    0 … 1
    prsb03-dataelement-13065link
    A photograph of the person for identification and to show what the person looks like normally.Mulitmedia file
    treetree draft  Place of birth
    0 … 1
    prsb03-dataelement-10884link
    The country of birth of the person.NHS data dictionary :- Country code (birth)
    treetree draft  Marital status
    0 … 1
    prsb03-dataelement-10885link
    An indicator to identify the legal marital status of the person.NHS data dictionary :- Person marital status
    treetree folder Immigration status
    0 … 1
    prsb03-dataelement-13293link
    Include details of the immigration status of the person, their permissions to live and receive care and support in the UK e.g. asylum seeker, indefinite leave to remain in the UK. Include start date, end date and any comments.
    treeblank treetree draft  Immigration status
    0 … 1
    prsb03-dataelement-13304link
    Details of the immigration status of the person, their permissions to live and receive care and support in the UK e.g. asylum seeker, indefinite leave to remain in the UK.Code :- 1: Asylum Seeker; 2: Exceptional leave to remain in UK; 3: Indefinite Leave to Remain in UK ;4: Limited Leave to Remain in UK; 5: No Recourse to Public Funds (NRPF); 6: Other Nationals; 7: Refugee; 8: Unaccompanied Asylum Seeker; 9 EU pre-settled status; 10: EU settled status
    treeblank treetree draft  Start date
    0 … 1
    prsb03-dataelement-13294link
    Start date of immigration statusDate and time
    treeblank treetree draft  End date
    0 … 1
    prsb03-dataelement-13295link
    End date of immigration statusDate and time
    treeblank treetree draft  Comment
    0 … 1
    prsb03-dataelement-13296link
    Relevant comments about the person's immigration statusFree text
    treetree draft  Organ and tissue donation
    0 … 1
    prsb03-dataelement-13847link
    Whether the person has given consent for organ and/or tissue donation or opted out of automatic donation where applicable. This is information provided by the national register.Flag: - Yes or No
    treetree draft  Overseas visitor status
    0 … 1
    prsb03-dataelement-10908link
    The charging category relating to an overseas visitor.NHS data dictionary :- Overseas visitor charging catergory
    folder GP practice
    1 … 1 Mandatory
    prsb03-dataelement-101link
    Details of the person's GP practice.
    treetree folder GP practice record entry
    0 … *
    prsb03-dataelement-10643link
    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
    treeblank treetree draft  GP name
    0 … 1
    prsb03-dataelement-10003link
    The name of the person's GP. If the person is registered with a GP practice, their usual GP name will be something volunteered by the person or their representative.Free text
    treeblank treetree draft  GP practice details
    0 … 1
    prsb03-dataelement-10002link
    Name and address of the person's registered GP practice Registered GP practice details are available from the Person Demographics Service (PDS), or volunteered from the person or their representative. Include details of the practice name and address.Free text
    treeblank treetree draft  GP practice identifier
    1 … 1 Mandatory
    prsb03-dataelement-10001link
    The identifier of the registered GP practice. NHS data dictionary : - General medical practice code (patient registration)
    treeblank treetree draft  GP opt out indicator
    0 … 1
    prsb03-dataelement-10004link
    Indication that the person has opted out of registering with a GP.SNOMED CT : - 1092961000000104 |Does not wish to register with an NHS general practitioner (finding)| OR 1092941000000100 |Family using private general practitioner (finding)|
    folder About me
    0 … 1
    prsb03-dataelement-466link
    About me
    treetree folder What is most important to me
    0 … 1
    prsb03-dataelement-12964link
    A description of what is most important to you.
    treetree folder People who are important to me
    0 … 1
    prsb03-dataelement-13009link
    Details of who is important to you and why. 
    treetree folder How I communicate and how to communicate with me
    0 … 1
    prsb03-dataelement-13006link
    A description of how you communicate normally. 
    treetree folder My wellness
    0 … 1
    prsb03-dataelement-13005link
    A description covering what you are able to do, how you engage with others and how you feel on a typical day through to on a day when you are unwell or really unwell.
    treetree folder Please do and please don't
    0 … 1
    prsb03-dataelement-13008link
    A description of things you want someone supporting you to do (or not to do). 
    treetree folder How and when to support me
    0 … 1
    prsb03-dataelement-13007link
    A description of how and when you want someone caring for you to support you.
    treetree folder Also worth knowing about me
    0 … 1
    prsb03-dataelement-13094link
    A description of what is also worth knowing about you for people caring or supporting you. 
    treetree draft  Date
    0 … 1
    prsb03-dataelement-10367link
    This is a record of the date that this information was last updated.Date and Time
    treetree draft  Supported to write this by
    0 … 1
    prsb03-dataelement-10368link
    Where relevant, this is a record of name, relationship/role and contact details of the individual who supported the person to write this section e.g. carer, family member, advocate, professional.Free text
    treetree folder About me
    0 … 1
    prsb03-dataelement-10366link
    This is a record of the things that a person feels it is important to communicate about their needs, strengths, values, concerns and preferences to others providing support and care.
    folder Individual requirements
    0 … 1
    prsb03-dataelement-160link
    The individual requirements of the person.
    treetree folder Reasonable adjustment
    0 … 1
    prsb03-dataelement-12991link
    A record of reasonable adjustments that must be provided by the service to comply with the Equality Act 2010.
    treeblank treetree folder Reasonable adjustment record entry
    0 … *
    prsb03-dataelement-13061link
    This is a reasonable adjustment record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items
    treeblank treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-13098link
    The location where the reasonable adjustment was identified.
    treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13357link
    The coded value for location.NHS Data dictionary : - Organisation data service code
    treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13358link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treetree draft  Reasonable adjustment flag
    0 … 1
    prsb03-dataelement-13874link

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

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

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

    SNOMED CT: - 1108111000000107 |Requires reasonable adjustments for health and care access (Equality Act 2010) (finding)|
    treeblank treeblank treetree folder Reasonable adjustment
    0 … 1
    prsb03-dataelement-13017link
    The reasonable adjustment required e.g. requires specific contact method, requires communication professional
    treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13505link
    The coded value for reasonable adjustmentSNOMED CT : - Accessible information standard^999002121000000109 |Accessible information - communication support simple reference set (foundation metadata concept)|^999002151000000104 |Accessible information - requires communication professional simple reference set (foundation metadata concept)|^999002131000000106 |Accessible information - requires specific contact method simple reference set (foundation metadata concept)|^999002141000000102 |Accessible information - requires specific information format simple reference set (foundation metadata concept)|Refsets for other categories in development
    treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13506link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treetree draft  Reasonable adjustment additional detail
    0 … 1
    prsb03-dataelement-13018link
    Further detail about the support required and the consequence of not providing it.Free text
    treeblank treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-13020link
    The date the reasonable adjustment was identified.Date and time
    treetree folder Impairment
    0 … 1
    prsb03-dataelement-13001link
    A record of any impairments for the person relating to reasonable adjustments.
    treeblank treetree folder Impairment record entry
    0 … *
    prsb03-dataelement-13062link
    This is an impairment record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items
    treeblank treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-13099link
    The location where the impairment was identified.
    treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13429link
    The coded value for location.NHS data dictionary: - Organisation code service
    treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13430link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treetree folder Impairment category
    0 … 1
    prsb03-dataelement-13022link
    The category of the impairment e.g. Autism, Dementia, Physical disability, Sensory disability - such as sight or hearing, Long-term condition
    treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13507link
    The coded value for impairment.SNOMED CT
    treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13508link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treetree draft  Impairment additional detail
    0 … 1
    prsb03-dataelement-13023link

    Description of what the person can do with the impairment, what they want to be able to do and how they should be supported to do it and what the consequences are of not providing the support.
    Where there is a sensory disability include sensory processing difficulties (e.g. affects to balance and movement, oversensitive, under-sensitive).
    Free text
    treeblank treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-13024link
    The date the impairment was identified.Date and time
    treetree folder Cognition
    0 … *
    prsb03-dataelement-10066link
    Details of the persons cognitive impairment.
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-11705link
    The date when the cognitive impairment was identified.Date and time
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-11706link
    The location where the cognitive impairment was identified.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13431link
    The coded value for location.NHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13432link
    Free text field to be used if no code is availableFree text
    treeblank treetree draft  Cognition
    0 … 1
    prsb03-dataelement-13669link
    The cognitive impairment to be considered when communicating with the person, child or their primary carer.Free text
    treetree folder Mobility
    0 … *
    prsb03-dataelement-10067link
    Details of the person's mobility needs.
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-11707link
    The date when the mobility needs were identified.Date and time
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-11710link
    The location where the mobility needs were identified.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13433link
    The coded value for location.NHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13434link
    Free text field to be used if no coded text available
    treeblank treetree folder Mobility needs
    0 … 1
    prsb03-dataelement-13670link
    The mobility needs of the person that allows movement between two spaces and achieves participation and a degree of independence.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13671link
    The coded value for mobility needsSNOMED CT: - ^999002551000000108 |Mobility findings simple reference set (foundation metadata concept)|
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13672link
    Free text field to be used if no code is availableFree text
    treetree folder Other individual requirements
    0 … *
    prsb03-dataelement-10835link
    Details of any other individual requirements the person may have
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-11711link
    The date when the other individual requirements were identified.Date and time
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-11712link
    The location where the other individual requirements were identified.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13435link
    The coded value for location.NHS data dictionary : - Organisation service code
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13436link
    Free text field to be used if no coded text available
    treeblank treetree draft  Other individual requirement
    0 … 1
    prsb03-dataelement-13673link
    Other individual requirements that a person may have.Free text
    folder Alerts
    0 … 1
    prsb03-dataelement-10741link
    Details of alerts.
    treetree folder Alerts record entry
    0 … *
    prsb03-dataelement-10916link
    This is an alerts record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items
    treeblank treetree draft  Alert
    0 … 1
    prsb03-dataelement-10742link
    Any significant information meriting a specific and highly visible warning to any user (e.g. metallic implant, potential dangerous pet).Free text
    folder Legal information
    0 … 1
    prsb03-dataelement-520link
    The legal information relating to the person.
    treetree folder Consent for information sharing
    0 … 1
    prsb03-dataelement-10421link
    Details of the person's consent for information sharing
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-11713link
    The date when the consent was givenDate and time
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-11714link
    The location where the consent was taken.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13451link
    The coded value for location.NHS data dictionary : - Organisation data service code
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13452link
    Free text field to be used if no code is availableFree text
    treeblank treetree draft  Consent for information sharing
    0 … 1
    prsb03-dataelement-13575link
    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.Free text
    treeblank treetree draft  Reason for consent not given
    0 … 1
    prsb03-dataelement-13778link
    Reason not given for consentFree text
    treetree folder Consent relating to child
    0 … *
    prsb03-dataelement-10422link
    Details of the person's consent relating to child
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-11732link
    The date when the person with responsibility for the child was identified.Date and time
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-11733link
    The location where the person with responsibility for the child was identified.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13674link
    The coded value for locationNHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13675link
    Free text field to be used if no coded text available
    treeblank treetree draft  Consent relating to child
    0 … 1
    prsb03-dataelement-13576link
    The person with parental responsibility or appointed guardian where a child lacks competency. Consideration of age and competency, applying Gillick competency or Fraser guidelines.Free text
    treetree folder Mental capacity assessment
    0 … *
    prsb03-dataelement-10424link
    Details of the persons mental capacity assessment
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-11688link
    The date when the mental capacity assessment was made.Date and time
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-11689link
    The location where the mental capacity assessment was made.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13449link
    The coded value for location NHS data dictionary : - Organisation code
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13450link
    Free text field to be used if no code is availableFree text
    treeblank treetree draft  Mental capacity assessment
    0 … 1
    prsb03-dataelement-13724link
    Whether an assessment of the mental capacity of the (adult) person has been undertaken, if so, what capacity the decision relates to and the outcome of the assessment. Also record best interests decision if person lacks capacity.Free text
    treeblank treetree draft  Location of document
    0 … 1
    prsb03-dataelement-13779link
    The location of the mental capacity assessment information.Free text or URL
    treetree folder Lasting power of attorney for health and welfare or court-appointed deputy (or equivalent)
    0 … 1
    prsb03-dataelement-10425link
    Details of the person's LPA record or equivalent
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-13630link
    The date the LPA was recordedDate and time
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-13631link
    The location where the LPA was given
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13632link
    The coded value for locationNHS data dictionary : - Organisation code
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13633link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Lasting power of attorney for health and welfare or court appointed deputy (or equivalent)
    0 … 1
    prsb03-dataelement-13634link
    Record of one or more people who have been given power (LPA) by the person when they had capacity to make decisions about their health and welfare should they lose capacity to make those decisions. To be valid, an LPA must have been registered with the Court of Protection. If life-sustaining treatment is being considered the LPA document must state specifically that the attorney has been given power to consent to or refuse life-sustaining treatment. Details of any person (deputy) appointed by the court to make decisions about the person’s health and welfare. A deputy does not have the power to refuse life-sustaining treatment.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13636link
    The coded value for the LPASNOMED CT: - ^999001951000000107 |Personal welfare lasting power of attorney findings simple reference set (foundation metadata concept)|
    treeblank treeblank treetree draft  Location of document
    0 … 1
    prsb03-dataelement-13776link
    The location of the LPA informationFree text or URL
    treeblank treeblank treetree draft  Name of LPA
    0 … 1
    prsb03-dataelement-13635link
    The names of any appointed people or deputiesFree text
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-13637link
    The contact details of the LPANHS data dictionary:- UK telephone number
    treetree folder Deprivation of Liberty Safeguards or equivalent
    0 … 1
    prsb03-dataelement-10426link
    Details of the person's Deprivation of Liberty Safeguards (DoLS) or equivalent
    treeblank treetree draft  Application date
    0 … 1
    prsb03-dataelement-13068link
    The date the application was madeDate and time
    treeblank treetree draft  Application status
    0 … 1
    prsb03-dataelement-13069link
    The status of the DOLs application.Free text : - Requested or authorised
    treeblank treetree draft  Deprivation of liberty safeguards or equivalent
    0 … 1
    prsb03-dataelement-13626link
    Record of Deprivation of Liberty Safeguards (DoLS) or equivalent, including the reason for this.Free text
    treeblank treetree draft  Start date of authorisation
    0 … 1
    prsb03-dataelement-13071link
    The date the DOLs was authorised.Data and time
    treeblank treetree draft  Planned or actual end date of authorisation
    0 … 1
    prsb03-dataelement-13072link
    The planned or actual end date of authorisation.Date and time
    treeblank treetree folder Performing professional
    0 … 1
    prsb03-dataelement-13073link
    The professional who applied for the DOLs.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-13074link
    The name of the professional.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-13075link
    The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-13076link
    The grade of the professional.Free text
    treeblank treeblank treetree draft  Speciality
    0 … 1
    prsb03-dataelement-13077link
    The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-13078link
    Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-13079link
    The name of the organisation the professional works for.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-13080link
    Contact details of the professionalNHS data dictionary - UK phone number
    treetree folder Mental health act or equivalent status
    0 … *
    prsb03-dataelement-10427link
    Details of the persons mental health act record
    treeblank treetree draft  Section start date
    0 … 1
    prsb03-dataelement-10920link
    The date the person was detained.Date and time
    treeblank treetree draft  Section end date
    0 … 1
    prsb03-dataelement-10921link
    The date the person was no longer detained.Date and time
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-11692link
    The location where the decision to detain the person was made under the mental health act.
    treeblank treetree folder Mental health act or equivalent status
    0 … 1
    prsb03-dataelement-13627link
    Record where a person diagnosed with a mental disorder is formally detained under the Mental health act or equivalent, including the section number. If person subject to Community Treatment Order or Conditional Discharge (or equivalent) record here.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13628link
    The coded value for mental health actNHS data dictionary: - Mental health act legal status classification code
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13629link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treetree draft  Supporting information
    0 … 1
    prsb03-dataelement-13755link
    If person subject to Community Treatment Order or Conditional Discharge (or equivalent) record here.NHS data dictionary : - Community treatment order
    treetree folder Advance decision to refuse treatment (ADRT)
    0 … 1
    prsb03-dataelement-10428link
    Details of the person's ADRT status.
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-13479link
    The date the ADRT was recorded.Date
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-13480link
    The location where the ADRT was recorded.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13481link
    The coded value of locationNHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13482link
    Free text field to be used if no coded text available
    treeblank treetree folder Advance decision to refuse treatment
    0 … 1
    prsb03-dataelement-13502link
    A record of an advance decision to refuse one or more specific types of future treatment, made by a person who had capacity at the time of recording the decision. The decision only applies when the person no longer has the capacity to consent to or refuse the specific treatment being considered. An ADRT must be in writing, signed and witnessed. If the ADRT is refusing life-sustaining treatment it must state specifically that the treatment is refused even if the person’s life is at risk.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13503link
    The coded value for advance decision to refuse treatment.SNOMED CT:- ^999002181000000105 |Advance decision to refuse treatment preference findings simple reference set (foundation metadata concept)|
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13504link
    Free text field to be used if no code is availableFree text
    folder Safeguarding
    0 … 1
    prsb03-dataelement-271link
    The safeguarding details of the person.
    treetree folder Safeguarding concerns
    0 … *
    prsb03-dataelement-10821link
    Details of safeguarding concerns
    treeblank treetree draft  Safeguarding indicator
    0 … 1
    prsb03-dataelement-13428link
    Indicates whether or not the hospital considers that there are safeguarding issues associated with the patient.Flag: No =N: Yes = Y
    treeblank treetree draft  Safeguarding concerns date
    0 … 1
    prsb03-dataelement-10172link
    The date the safeguarding concerns were identified.Date and time
    treeblank treetree draft  Safeguarding concerns end date
    0 … 1
    prsb03-dataelement-10766link
    The date safeguarding concerns ended.Date and time
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-10173link
    The location where the safeguarding concerns were identified.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13437link
    The coded value of locationNHS data dictionary : - Organisation code
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13438link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Safeguarding concerns
    0 … 1
    prsb03-dataelement-10171link
    Identified safeguarding concerns.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13756link
    The coded value for safeguarding concernsSNOMED CT : - ^999002381000000108 | Safeguarding issues simple reference set (foundation metadata concept) |
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13757link
    Free text field to be used if no code is availableFree text
    treeblank treetree draft  Comment
    0 … 1
    prsb03-dataelement-10175link
    Further details on safeguarding concerns.Free text
    treetree folder Looked after child
    0 … *
    prsb03-dataelement-10797link
    Details of the looked after child
    treeblank treetree draft  Looked after child start date
    0 … 1
    prsb03-dataelement-10746link
    The date the child became a looked after child.Date and time
    treeblank treetree draft  Looked after child end date
    0 … 1
    prsb03-dataelement-10761link
    The date the child ceased to be a looked after child.Date and time
    treeblank treetree folder Local authority
    0 … 1
    prsb03-dataelement-10799link
    The named local authority.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13614link
    The coded value for local authorityNHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13615link
    Free text field to be used if no code is availableFree text
    treetree folder Child protection plan
    0 … *
    prsb03-dataelement-10798link
    Details of the child protection plan
    treeblank treetree draft  Child protection plan start date
    0 … 1
    prsb03-dataelement-10747link
    The start date of the child protection planDate and time
    treeblank treetree draft  Child protection plan end date
    0 … 1
    prsb03-dataelement-10762link
    The end date of the child protection planDate and time
    treeblank treetree folder Local authority
    0 … 1
    prsb03-dataelement-10748link
    The named local authority.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13616link
    The coded value for a local authorityNHS data dictionary : - organisation data service
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13617link
    Free text field to be used if no code is availableFree text
    treetree folder Unborn child protection plan
    0 … *
    prsb03-dataelement-10923link
    Details of the unborn child protection plan.
    treeblank treetree draft  Unborn child protection plan start date
    0 … 1
    prsb03-dataelement-10924link
    Start date of the unborn child protection plan.Date and time
    treeblank treetree draft  Unborn child protection plan end date
    0 … 1
    prsb03-dataelement-10925link
    End date of the unborn child protection plan.Date and time
    treeblank treetree folder Local authority
    0 … 1
    prsb03-dataelement-10926link
    The named local authority.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13618link
    The coded value for local authorityNHS data dictionary: - Organisation data service
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13619link
    Free text field to be used if no code is availableFree text
    folder Professional contacts
    0 … 1
    prsb03-dataelement-452link
    The details of the person’s professional contacts.
    treetree folder Professional contacts record entry
    0 … *
    prsb03-dataelement-10767link
    This is a professional contacts record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
    treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-10352link
    The name of the professional with responsibility for the care of the person.Free text
    treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-10353link
    The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker, key worker, care home manager, care coordinator, LA hospital liaison person, care home contact, hospital clinician, Independent Mental Capacity Advocate (IMCA) etcFHIR value set : - SDSjobrole
    treeblank treetree draft  Key worker
    0 … 1
    prsb03-dataelement-12973link
    A flag that identifies the personal contact is the key worker assigned to the person.Flag : - Yes or No
    treeblank treetree draft  Speciality
    0 … 1
    prsb03-dataelement-10354link
    The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary : - Activity treatment function code
    treeblank treetree draft  Team
    0 … 1
    prsb03-dataelement-10355link
    The name of the team.Free text
    treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-10356link
    The name of the organisation.
    treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-10357link
    Contact details of the professional (e.g. telephone number, email address etc.).Free text
    treeblank treetree draft  Start date
    0 … 1
    prsb03-dataelement-10358link
    The start date of the professional relationship with the person.Date and time
    treeblank treetree draft  End date
    0 … 1
    prsb03-dataelement-10359link
    The end date of the professional relationship with the person.Date and time
    folder Personal contacts
    0 … 1
    prsb03-dataelement-445link
    The details of the individual's personal contacts.
    treetree folder Personal contacts record entry
    0 … *
    prsb03-dataelement-10768link
    This is personal contacts record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
    treeblank treetree draft  Name
    1 … 1 Mandatory
    prsb03-dataelement-10345link
    The name of the personal contact.Free text
    treeblank treetree draft  Relationship
    0 … 1
    prsb03-dataelement-10346link
    The relationship the personal contact has to the person, e.g. father, grandmother, family friend etc.FHIR value set : - Related person
    treeblank treetree draft  Relationship type
    0 … 1
    prsb03-dataelement-12968link
    Additional roles the person performs on behalf of the other (e.g. Carer, Next of Kin, Emergency Contact, Dependent, etc.)Free text
    treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-10350link
    Contact details of the personal contact (e.g. telephone number, email address etc.)Free Text
    treeblank treetree draft  Comments
    0 … 1
    prsb03-dataelement-10937link
    Notes on the significance of the personal contact to the person.Free text
    folder Participation in research
    0 … 1
    prsb03-dataelement-168link
    Participation in research
    treetree folder Participation in research record entry
    0 … *
    prsb03-dataelement-10646link
    This is a Participation in research record entry. There may be 0 to many record entry/entries under a section. Each record entry is made up of a number of elements or data items.
    treeblank treetree draft  Name of research study
    0 … 1
    prsb03-dataelement-10068link
    Name and details of the research study/trial and/or drug/interventionFree text or URL
    treeblank treetree draft  Identification code
    0 … 1
    prsb03-dataelement-10739link
    Identification code of research studyNHS data dictionary :- Clinical trial identifier
    folder Referral details
    0 … 1
    prsb03-dataelement-105link
    The details of the referral.
    treetree folder Referral details record entry
    0 … *
    prsb03-dataelement-10917link
    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.
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-10006link
    The date of referralDate and time
    treeblank treetree folder Referrer details
    0 … 1
    prsb03-dataelement-10005link
    The details of the referrer that is making the referral or the transfer.

    This could be the person, GP surgery, department, specialty, sub-specialty, educational institution, mental health team, care home etc.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-10971link
    The name of the referrer.Free text
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-10972link
    Role of the referrer.FHIR value set : - sdsjobrole
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-10973link
    The grade of the referrer.Free text
    treeblank treeblank treetree draft  Team
    0 … 1
    prsb03-dataelement-12409link
    The team or department of the referrer.Free text
    treeblank treeblank treetree draft  Specialty
    0 … 1
    prsb03-dataelement-12410link
    The specialty of the referrer.NHS data dictionary - Activity treatment function code
    treeblank treeblank treetree folder Service
    0 … 1
    prsb03-dataelement-12411link
    The service of the referrer.
    treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13397link
    The coded value for serviceSNOMED CT: - 1127531000000102 |Services simple reference set (foundation metadata concept)|
    treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13398link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-10974link
    The organisation of the referrer.
    treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13399link
    The coded value for organisation codeNHS data dictionary : - Organisation data service
    treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13400link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-10975link
    The contact details of the referrer.Free text
    treeblank treetree draft  Referral method
    0 … 1
    prsb03-dataelement-10007link
    The method in which a referral is sent and received. This may be a letter, email, transcript of a telephone conversation, Choose and Book, in person (self-referral) etc.Allow National Codes only Fax Phone Secure Messaging Secure Email Letter NHS E-Referral Service Self referral
    treeblank treetree folder Reason for referral
    0 … 1
    prsb03-dataelement-10011link
    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.Free text
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13455link
    The coded value for reason for referralSNOMED CT :- ^1127581000000103 |Health issues simple reference set|
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13456link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Clinical urgency of referral
    0 … 1
    prsb03-dataelement-10010link
    The details of the clinical urgency of referral
    treeblank treeblank treetree draft  Reason for urgency of referral
    0 … 1
    prsb03-dataelement-10976link
    The reason for urgency of referral if not routine.Free text
    treeblank treetree folder Referral to
    0 … 1
    prsb03-dataelement-10008link
    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.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-10977link
    Name of person the referral is to be sent to.Free text
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-10978link
    Role of person where the referral is to be sent to.FHIR value set : - sdsjobrole
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-10979link
    The grade of the person where the referral is sent to.Free text
    treeblank treeblank treetree draft  Team
    0 … 1
    prsb03-dataelement-10982link
    The team or department of the person where the referral is being sent toFree text.
    treeblank treeblank treetree draft  Specialty
    0 … 1
    prsb03-dataelement-10983link
    The specialty the referral is being sent to e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
    treeblank treeblank treetree folder Service
    0 … 1
    prsb03-dataelement-12412link
    The service of where the referral is sent to.
    treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13509link
    The coded value for serviceSNOMED CT: - 1127531000000102 |Services simple reference set (foundation metadata concept)|
    treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13510link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-10980link
    The organisation of where the referral is to be sent.
    treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13511link
    The coded value for organisationNHS data dictionary :- Organisation data service
    treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13512link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-10981link
    The contact details of where the referral is to be sent.Free text.
    treeblank treetree draft  Referral criteria
    0 … 1
    prsb03-dataelement-10014link
    Records whether specific criteria required for referral, to a particular service, have been met (may be nationally or locally determined). This field is used to outline which criteria have been met where a service has indicated specific criteria and to explain the rationale for referral where criteria have not been met.Free text
    treeblank treetree draft  Return response to
    0 … 1
    prsb03-dataelement-10015link
    Name of professional to be communicated with, if not the referrerFree text.
    folder Contacts with professionals
    0 … 1
    prsb03-dataelement-169link
    The details of the person’s contact with a professional.
    treetree folder Contacts with professionals record entry
    0 … *
    prsb03-dataelement-10718link
    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.
    treeblank treetree draft  Date of contact
    0 … 1
    prsb03-dataelement-10069link
    Date and time of the contact.Date and time.
    treeblank treetree folder Location of contact
    0 … 1
    prsb03-dataelement-10075link
    The location where the contact took place.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13513link
    The coded value for locationNHS data dictionary : - Organisation service code
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13514link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Seen by
    0 … 1
    prsb03-dataelement-10077link
    The professional that saw the person.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-13515link
    The name of the professional that saw the personFree text
    treeblank treeblank treetree cancelled  Free text
    0 … 1
    prsb03-dataelement-13516link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Responsible professional
    0 … 1
    prsb03-dataelement-10072link
    The name and role of the professional that had overall responsibility for the person e.g. consultant, nurse consultant, midwife, allied health professional (may not have actually seen the person).
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-10988link
    The name of the responsible professional.Free text
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-10989link
    The role of the responsible professionalFHIR value set : - sdsjobrole
    treeblank treetree draft  Location type
    0 … 1
    prsb03-dataelement-10076link
    The type of location where the contact took place e.g. person's homeNHS data dictionary - Activity location type code
    treeblank treetree draft  Contact type
    0 … 1
    prsb03-dataelement-10070link
    Type of contact e.g. GP consultation, outpatient attendanceFree text
    treeblank treetree draft  Consultation method
    0 … 1
    prsb03-dataelement-10071link
    Consultation method used e.g. face to face, telephoneNHS data dictionary - Consultation medium
    treeblank treetree draft  Specialty
    0 … 1
    prsb03-dataelement-10073link
    The specialty e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
    treeblank treetree draft  Service
    0 … 1
    prsb03-dataelement-10074link
    The service that was provided.SNOMED CT :- 1127531000000102 |Services simple reference set (foundation metadata concept)|
    treeblank treetree folder Professionals present
    0 … *
    prsb03-dataelement-10078link
    The name, role of the additional individuals or team members including consultant(s), nurse consultant(s), allied health professional(s), social worker(s)
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-10990link
    The name of the professional presentFree text
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-10991link
    The role of the professional present.FHIR value set : - sdsjobrole
    treeblank treetree draft  Outcome of contact
    0 … 1
    prsb03-dataelement-10080link
    This records the outcome of the contact. NHS data dictionary :- Attended or did not attend code
    folder Admission details
    0 … 1
    prsb03-dataelement-181link
    Admission details
    treetree folder Admission details record entry
    0 … *
    prsb03-dataelement-10918link
    This is the admission details record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
    treeblank treetree draft  Date of admission
    0 … 1
    prsb03-dataelement-10085link
    Date and time the person was admitted to hospital.Date and time
    treeblank treetree folder Admitted to
    0 … 1
    prsb03-dataelement-10090link
    The hospital the person was admitted to.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13380link
    The coded value for admission toNHS data dictionary : - Organisations code of provider
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13381link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Responsible care professional
    0 … 1
    prsb03-dataelement-10087link
    The care professional who has overall responsibility for the person (may not actually see the person)
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-10992link
    The name of the responsible care professional.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-10993link
    The role of the responsible consultant.FHIR value set: - sdsjobrole
    treeblank treetree folder Reason for admission
    0 … 1
    prsb03-dataelement-10081link
    The health problems and issues experienced by the person that prompted the decision to admit to hospital e.g. chest pain, mental health crisis, blackout, fall, a specific procedure, intervention, investigation or treatment, non compliance with treatment.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13382link
    The coded value for reason for admissionSNOMED CT: - ^1127581000000103 |Health issues simple reference set|
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13384link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Admission method
    0 … 1
    prsb03-dataelement-10082link
    How the person was admitted to hospital e.g. elective, emergency, maternity, transfer etc.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13385link
    The coded value for admission methodNHS data dictionary : - Admission method
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13387link
    Free text field to be used if no code is availableFree text
    treeblank treetree draft  Legal status on admission
    0 … 1
    prsb03-dataelement-10083link
    Whether the person was admitted as informal or formal/detained.NHS data dictionary : - Mental health act legal status classification code
    treeblank treetree folder Source of admission
    0 … 1
    prsb03-dataelement-10084link
    Where the person was immediately prior to admission, e.g. usual place of residence, temporary place of residence, penal establishment.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13388link
    The coded value of source of admissionNHS data dictionary :- Source of admission
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13389link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Individual accompanying person
    0 … 1
    prsb03-dataelement-10088link
    Details of the accompanying individual and the extent to which they have provided the information about the person.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-10984link
    Name of individual accompanying person.Free text
    treeblank treeblank treetree cancelled  Role
    0 … 1
    prsb03-dataelement-10985link
    Role of the individual accompanying the person.NHS data dictionary : - Care professional
    treeblank treeblank treetree folder Relationship
    0 … 1
    prsb03-dataelement-10986link
    Relationship of individual accompanying the person.
    treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13517link
    The coded value for relationship to person.FHIR value set: - Relationship type
    treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13518link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treetree draft  Comment
    0 … 1
    prsb03-dataelement-12447link
    Information about the extent to which the accompanying individual provided information about the person.Free text.
    treeblank treetree folder Specialty
    0 … 1
    prsb03-dataelement-10089link
    The specialty e.g. physiotherapy, oncology, mental health etc
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13390link
    The coded value for specialtyNHS data dictionary :- Activity treatment function code
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13391link
    Free text field to be used if no code is availableFree text
    folder Discharge details
    0 … 1
    prsb03-dataelement-191link
    Discharge details
    treetree folder Discharge details record entry
    0 … *
    prsb03-dataelement-10919link
    This is the discharge details record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
    treeblank treetree draft  Date of discharge
    0 … 1
    prsb03-dataelement-10096link
    The date and time of dischargeDate and time
    treeblank treetree draft  Discharge location
    0 … 1
    prsb03-dataelement-10095link
    The hospital the person was discharged from.NHS data dictionary : - Organisation data service
    treeblank treetree folder Discharging consultant
    0 … 1
    prsb03-dataelement-10093link
    The consultant responsible for the person at time of discharge.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-10994link
    The name of the discharging consultantFree text
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-10995link
    The role of the discharging consultantFHIR value set : - sdsjobrole
    treeblank treetree folder Discharge method
    0 … 1
    prsb03-dataelement-10098link
    The method of discharge from hospital e.g. person discharged on clinical advice or with clinical consent; person discharged him/herself or was discharged by a relative or advocate.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13393link
    The coded value for discharge methodNHS data dictionary : - Discharge method
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13394link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Discharging specialty
    0 … 1
    prsb03-dataelement-10094link
    The specialty of the consultant responsible for the person at the time of discharge.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13395link
    The coded value for discharge specialityNHS data dictionary : - Activity treatment function code
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13396link
    Free text field to be used if no code is availableFree text
    treeblank treetree draft  Discharging department
    0 … 1
    prsb03-dataelement-10987link
    The department from which the person is discharged.Free text
    treeblank treetree draft  Legal status on discharge
    0 … 1
    prsb03-dataelement-10097link
    Whether the person was discharged as informal or formal/detained.NHS data dictionary : - Mental health act classification code
    treeblank treetree folder Discharge destination
    0 … 1
    prsb03-dataelement-10099link
    treeblank treeblank treetree draft  Discharge destination
    0 … 1
    prsb03-dataelement-10100link
    The destination of the person on discharge from hospital e.g. usual place of residence, NHS run care home.NHS data dictionary - Discharge destination.
    treeblank treeblank treetree draft  Discharge address
    0 … 1
    prsb03-dataelement-10101link
    Address to which the person is discharged if not the usual place of residence.NHS data dictionary :- Address
    folder Future appointments
    0 … 1
    prsb03-dataelement-10720link
    Details of future appointments.
    treetree folder Future appointments record entry
    0 … *
    prsb03-dataelement-10721link
    This is the future appointments record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
    treeblank treetree draft  Date of appointment
    0 … 1
    prsb03-dataelement-10722link
    Date and time of future appointment.Date and time
    treeblank treetree draft  Appointment status
    0 … 1
    prsb03-dataelement-10723link
    The status of the appointment e.g. proposed, booked, confirmed, rejected.Free text
    treeblank treetree draft  Reason for appointment
    0 … 1
    prsb03-dataelement-10724link
    Reason this appointment is scheduled e.g. diagnosis, investigation, treatment or assessmentFree text
    treeblank treetree folder Location of future appointment
    0 … 1
    prsb03-dataelement-10726link
    The location of the appointment.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13519link
    The coded value for locationNHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13520link
    Free text field to be used if no code is availableFree text
    treeblank treetree draft  Specialty
    0 … 1
    prsb03-dataelement-10727link
    The specialty e.g. physiotherapy, oncology, mental health etc. NHS data dictionary :- Activity treatment function code
    treeblank treetree draft  Service
    0 … 1
    prsb03-dataelement-10728link
    The service being provided.SNOMED CT: - 1127531000000102 |Services simple reference set (foundation metadata concept)|
    treeblank treetree folder Professional to see the person
    0 … 1
    prsb03-dataelement-10729link
    The name and role of the professional e.g. consultant, care worker, nurse consultant.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-12413link
    The name of the professional seeing the person.Free text
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-12414link
    The role of the professional seeing the person.FHIR value set : - sdsjobrole
    folder Vaccinations
    0 … 1
    prsb03-dataelement-10685link
    Details of vaccinations.
    treetree folder Vaccinations record entry
    0 … *
    prsb03-dataelement-10686link

    This is the vaccinations record entry.

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

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

    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-10695link
    The date on which the vaccination was administered or the reported/partial date on which it was reported.Date and time
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-10759link
    The location where the vaccine was administered.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13577link
    The coded value for locationNHS data dictionary: - Organisation data service
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13578link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Vaccine product
    1 … 1 Mandatory
    prsb03-dataelement-10687link
    The vaccine product administered.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13237link
    The coded value for vaccine product.dm+d (SNOMED) Concept ID AMP (preferred) or VMP term for the vaccine product
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13238link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Manufacturer
    0 … 1
    prsb03-dataelement-10698link
    Name of vaccine manufacturer.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13239link
    The coded value of the manufacturer.SNOMED CT: - DM+D or GS1
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13240link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Vaccine procedure
    1 … 1 Mandatory
    prsb03-dataelement-10688link
    The procedure which was used to administer the vaccine.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13219link
    The coded value for vaccine procedureSNOMED CT :- < 127785005 |Administration of substance to produce immunity, either active or passive (procedure)| or  << 1066171000000108 Seasonal influenza vaccination given by midwife or << 713404003 Vaccination given (code and all its descendants)
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13220link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Body site
    0 … 1
    prsb03-dataelement-10691link
    Body site vaccine was administered.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13222link
    The coded value for body siteSNOMED CT : - ^1127941000000100 |Vaccine body site of administration simple reference set (foundation metadata concept)|
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13223link
    Free text field to be used if no coded text available
    treeblank treetree folder Route
    0 … 1
    prsb03-dataelement-10692link
    How the vaccine entered the body.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13224link
    The coded value for vaccination routeSNOMED CT: - ^999000051000001100 |ePrescribing route of administration simple reference set (foundation metadata concept)|
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13225link
    Free text field to be used if no coded text available
    treeblank treetree folder Indication
    0 … 1
    prsb03-dataelement-10693link
    The clinical indication or reason for administering the vaccine.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13226link
    The coded value for Indication.SNOMED CT:- ^1127601000000107 | Healthcare matters simple reference set (foundation metadata concept) |
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13227link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Dose amount
    0 … 1
    prsb03-dataelement-10694link
    Amount of vaccine administered.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13228link
    Amount of vaccine administered.SNOMED CT : - dm+d
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13229link
    Amount of vaccine administered.Free text
    treeblank treetree draft  Dose sequence
    0 … 1
    prsb03-dataelement-10824link
    Nominal position in a series of vaccines.Numeric value
    treeblank treetree folder Outcome status
    0 … 1
    prsb03-dataelement-10838link
    Whether the vaccine was administered or not, including the reason why
    treeblank treeblank treetree draft  Not given flag
    0 … 1
    prsb03-dataelement-13230link
    Flag to indicate that the vaccination was NOT given at this time by a healthcare professionalFlag: - Yes or No
    treeblank treeblank treetree draft  Vaccination situation (not given reason)
    0 … 1
    prsb03-dataelement-13231link
    The reason why a vaccination was not administered.FHIR value set : - Reason code
    treeblank treetree folder Reported
    0 … 1
    prsb03-dataelement-10825link
    Details of the vaccination reported to the professional
    treeblank treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-10837link
    The date or partial date that the reported vaccination was given in the opinion of the person.Date/time
    treeblank treeblank treetree draft  Reported
    0 … 1
    prsb03-dataelement-13849link
    A flag to indicate the information was reported to a professionalFlag: - Yes or No
    treeblank treeblank treetree draft  Report origin
    0 … 1
    prsb03-dataelement-13232link
    The source of the data when the report of the vaccination event is not based on information from the person who administered the vaccine.FHIR value set:- https://www.hl7.org/fhir/valueset-immunization-origin.html
    folder Problem list
    0 … 1
    prsb03-dataelement-10927link
    A summary of the problems that require investigation or treatment.
    treetree folder Problem list record entry
    0 … *
    prsb03-dataelement-10928link
    This is a problem list record entry.

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

    Each record entry is made up of a number of elements or data items.
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-10929link
    The date the problem was identified.Date and time
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-10931link
    The location the problem was identified.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13242link
    The coded value for location.NHS data dictionary : - Organisation data service code
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13243link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Problem
    1 … 1 Mandatory
    prsb03-dataelement-10932link
    A condition which needs addressing and so is important for every professional to know about when seeing the person.

    Problems may include diagnoses, symptoms, disabilities and social or behavioural issues
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13244link
    The coded value for the problem list.SNOMED CT : - ^1127581000000103 |Health issues simple reference set|
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13245link
    Free text field to be used if no code is availableFree text
    treeblank treetree draft  Onset date
    0 … 1
    prsb03-dataelement-10933link
    A date or estimated date that the problem beganDate and time
    treeblank treetree draft  End Date
    0 … 1
    prsb03-dataelement-10934link
    The date or estimated date the problem was resolved.Date and time.
    treeblank treetree draft  Stage of disease
    0 … 1
    prsb03-dataelement-10935link
    The stage of the disease where relevant.Free text
    treeblank treetree draft  Comment
    0 … *
    prsb03-dataelement-10936link
    Supporting text may be given covering the problem.Free text
    folder Procedures and therapies
    0 … 1
    prsb03-dataelement-238link
    The details of any procedures performed. Includes both psychological and medical therapies and procedures (e.g. cognitive behaviour therapy, hip replacement)
    treetree folder Procedure record entry
    0 … *
    prsb03-dataelement-10652link
    This is a procedure record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-10138link
    The date the procedure was performed.Date and time.
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-13246link
    The location where the procedure was undertaken.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13247link
    The coded value for location.NHS data dictionary : - Organisation data service code
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13248link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Procedure
    1 … 1 Mandatory
    prsb03-dataelement-10141link
    The therapeutic or diagnostic procedure performed. Includes both psychological and medical therapies and procedures (e.g. cognitive behaviour therapy, or follow-up interventions as a result of physical health checks). Complementary or alternative procedures and therapies should be recorded here.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13249link
    The procedure code.SNOMED CT : - <<71388002 |Procedure| OR <<129125009 |Procedure with explicit context|
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13250link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Anatomical site
    0 … 1
    prsb03-dataelement-10142link
    The body site of the procedure
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13251link
    The coded value of the anatomical site.SNOMED CT :- <123037004 |Body structure (body structure)|
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13252link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Laterality
    0 … 1
    prsb03-dataelement-10143link
    Laterality of the procedure
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13253link
    The coded value for laterality.SNOMED CT:- <182353008 |Side (qualifier value)|
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13254link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Complications related to procedure
    0 … 1
    prsb03-dataelement-10144link
    Details of any intra-operative complications encountered during the procedure, arising during the person’s stay in the recovery unit or directly attributable to the procedure.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13255link
    The coded value for complications relating to procedure.SNOMED CT : - <404684003 |Clinical finding (finding)|
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13256link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Specific anesthesia issues
    0 … 1
    prsb03-dataelement-10145link
    Details of any adverse reaction to any anesthetic agents including local anesthesia. Problematic intubation, transfusion reaction, etc.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13257link
    The coded value for specific anesthesia issues.SNOMED CT
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13258link
    Free text field to be used if no code is availableFree text
    treeblank treetree draft  Comment
    0 … 1
    prsb03-dataelement-10146link
    Any further textual comment to clarify such as statement that information is partial or incomplete. Also indicate the outcome of the procedure.Free text
    folder Social context
    0 … 1
    prsb03-dataelement-136link
    The social setting in which the person lives, such as their household, occupational history, and lifestyle factors.
    treetree folder Household composition
    0 … 1
    prsb03-dataelement-10036link
    Details of the person's household composition.
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-11770link
    The date when the household composition was taken.Date and time.
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-13271link
    The location where the household composition was taken.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13272link
    The coded value for location.NHS data dictionary : - Organisation data service code
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13273link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Household composition
    0 … 1
    prsb03-dataelement-13261link
    Description of the household composition e.g. lives alone, lives with family, lives with partner, etc.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13262link
    The coded value of household compositionSNOMED CT: - 1027891000000106 | Household composition findings simple reference set (foundation metadata concept) |
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13263link
    Free text field to be used if no code is availableFree text
    treetree folder Occupational history
    0 … 1
    prsb03-dataelement-10037link
    The current and/or previous occupation(s) of the person.
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-11772link
    The date when the occupational history was taken.Date and time.
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-11773link
    The location where the occupational history was taken.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13274link
    The coded value for the location.NHS Data dictionary : - Organisation data service code
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13275link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Occupational history
    0 … 1
    prsb03-dataelement-13264link
    The current and/or previous occupation(s) of the person.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13265link
    The coded value for occupational historySNOMED CT : - ^999001571000000109 | Occupation simple reference set (foundation metadata concept)
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13266link
    Free text field to be used if no code is availableFree text
    treetree folder Educational history
    0 … 1
    prsb03-dataelement-10038link
    Details of the person's educational history.
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-11774link
    The date when the educational history was taken.Date and time.
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-11775link
    The location where the education history was taken.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13276link
    The coded value for location.NHS Data dictionary : - Organisation data service code
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13277link
    Free text field to be used if no code is availableFree text
    treeblank treetree draft  Educational history
    0 … 1
    prsb03-dataelement-13840link
    The current and/or previous relevant educational history of the person.Free text
    treetree folder Lifestyle choices
    0 … 1
    prsb03-dataelement-10039link
    The lifestyle choices made by the person which are pertinent to his or her health and well-being, e.g. physical activity level, pets, hobbies and sexual habits
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-11784link
    The date when the lifestyle choices were taken.Date and time.
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-11785link
    The location where the lifestyle choices were taken.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13278link
    The coded value for location.NHS Data dictionary : - Organisation data service code
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13279link
    Free text field to be used if no code is availableFree text
    treeblank treetree draft  Lifestyle choices
    0 … 1
    prsb03-dataelement-13841link
    The lifestyle choices made by the person which are pertinent to his or her health and well-being, e.g. physical activity level, pets, hobbies and sexual preferences.Free text
    treetree folder Smoking status
    0 … 1
    prsb03-dataelement-10040link
    Details of the person's smoking status.
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-11794link
    The date when the smoking status was taken.Date and time
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-11795link
    The location where the smoking status was taken.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13281link
    The coded value for locationNHS data dictionary : - Organisation data service code
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13282link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Smoking status
    0 … 1
    prsb03-dataelement-13283link
    Record of any smoking use by the person.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13284link
    The smoking status of the person.SNOMED CT:- ^999000891000000102 |Smoking simple reference set (foundation metadata concept)|
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13285link
    Free text field to be used if no code is availableFree text
    treeblank treetree draft  Smoking status - details
    0 … 1
    prsb03-dataelement-13286link
    Further details recorded about the smoking status of the personFree text
    treeblank treetree folder Date stopped smoking
    0 … 1
    prsb03-dataelement-13287link
    The date the person stopped smoking (if known)
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13288link
    The coded value for date stopped smoking.SNOMED CT:- 160625004 |Date ceased smoking (observable entity)|
    treeblank treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-13289link
    The date the person stopped smoking.Date and time
    treetree folder Alcohol intake
    0 … 1
    prsb03-dataelement-10041link
    Details of the person's alcohol intake
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-11804link
    The date when the alcohol intake was noted.Date and time
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-11805link
    The location where the alcohol intake was noted.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13332link
    The coded value for location.NHS Data dictionary : - Organisation data service code
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13333link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Alcohol intake
    0 … 1
    prsb03-dataelement-13290link
    Latest or current alcohol consumption.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13291link
    The coded value of the person alcohol intakeSNOMED CT :- 219006 |Current drinker of alcohol (finding)| OR 105542008 |Current non-drinker of alcohol (finding)| OR 228274009 |Lifetime non-drinker (finding)| OR 1104551000000109 |Declined to provide information about alcohol use (situation)| OR 371434005 |History of alcohol abuse (situation)|
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13292link
    Free text field to be used if no code is availableFree text
    treetree folder Drug/substance use
    0 … 1
    prsb03-dataelement-10042link
    Details of the person's drug and substance use.
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-11814link
    The date when the drug/substance use was noted.Date and time
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-11815link
    The location where the drug/substance use was noted.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13334link
    The coded value for location.NHS Data dictionary : - Organisation data service code
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13335link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Drug/substance use
    0 … 1
    prsb03-dataelement-13336link
    Latest or current drug/substance use.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13337link
    The coded value for drug and substance misuse.SNOMED CT:- 361055000 |Misuses drugs (finding)| OR 371422002 |History of substance abuse (situation)| OR 228368007 |Has never misused drugs (situation)| OR 783241000000102 |Declined to give substance misuse history (finding)|
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13338link
    Free text field to be used if no code is availableFree text
    treetree folder Social circumstances
    0 … 1
    prsb03-dataelement-10043link
    Details of the persons social circumstances
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-11824link
    The date when the social circumstances were taken.Date and time
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-11825link
    The location where the social circumstances were taken.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13339link
    The coded value for the location
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13340link
    Free text field to be used if no code is availableFree text
    treeblank treetree draft  Social circumstances
    0 … 1
    prsb03-dataelement-13341link
    A person’s social background, network and personal circumstances, e.g. housing. This should include whether the person is a carer.Free text
    treetree folder Access
    0 … 1
    prsb03-dataelement-10045link
    Details of access for the person.
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-11844link
    The date when the special access requirements were taken.Date and time
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-11845link
    The location where the special access requirements were taken.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13343link
    The coded value for locationNHS Data dictionary : - Organisation data service code
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13344link
    Free text field to be used if no coded text available
    treeblank treetree draft  Access
    0 … 1
    prsb03-dataelement-13342link
    Special access requirements e.g. key safe, coded lock, which door to use, stretcher access, etc.Free text
    treetree folder Dependants
    0 … 1
    prsb03-dataelement-10046link
    Details of any responsibility the person has for dependants.
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-11854link
    The date when the dependents details were taken.Date and time
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-11855link
    The location where the dependents details were taken.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13346link
    The coded value for locationNHS Data dictionary : - Organisation data service code
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13347link
    Free text field to be used if no code is availableFree text
    treeblank treetree draft  Dependants
    0 … 1
    prsb03-dataelement-13345link
    Provide details of any responsibility the person has for dependants. In the case of children provide date of birth of the child.Free text
    treetree folder Accommodation status
    0 … 1
    prsb03-dataelement-10047link
    Details of the type of accommodation where the person lives.
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-11864link
    The date when the accommodation status was taken.Date and time
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-11865link
    The location where the accommodation was taken.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13352link
    The coded value of locationNHS Data dictionary : - Organisation data service code
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13353link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Accommodation status
    0 … 1
    prsb03-dataelement-13348link
    An indication of the type of accommodation where the person lives.

    This should be based on the main or permanent residence.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13349link
    The coded value for accommodation statusNHS data dictionary :- Accommodation status
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13350link
    Free text field to be used if no code is availableFree text
    treetree folder Household environment
    0 … 1
    prsb03-dataelement-10051link
    Details of the person's household environment.
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-11883link
    The date when the household environment details were taken.Date and time
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-11884link
    The location where the household environment details were taken.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13351link
    The coded value for locationNHS Data dictionary : - Organisation data service code
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13354link
    Free text field to be used if no code is availableFree text
    treeblank treetree draft  Household environment
    0 … 1
    prsb03-dataelement-13842link
    Factors in the household which impact the person's health and wellbeing, to include smoking in the home, alcohol/substance use etc.Free text
    folder Services and care
    0 … 1
    prsb03-dataelement-10044link
    The services and care provided for the person.
    treetree folder Services and care record entry
    0 … *
    prsb03-dataelement-12421link
    This is a services and care record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
    treeblank treetree draft  Social care package name
    0 … 1
    prsb03-dataelement-12965link
    Name of specific type of package being provided (e.g. Reablement, Home Based Care XYZ, etc)Free text
    treeblank treetree draft  Social care package type
    0 … 1
    prsb03-dataelement-12966link
    Higher level categorisation of package type, e.g. Adults Home SupportFree text
    treeblank treetree draft  Service start date
    0 … 1
    prsb03-dataelement-11834link
    The date service started to be provided.Date and time
    treeblank treetree draft  Service end date
    0 … 1
    prsb03-dataelement-12420link
    The date the service is planned to be ended or the actual end date.Date and time
    treeblank treetree folder Local authority
    0 … 1
    prsb03-dataelement-11835link
    The name of the local authority providing the care package.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13566link
    The coded value for local authorityNHS data dictionary: - Organisation data service
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13567link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Care funding source
    0 … 1
    prsb03-dataelement-13067link
    A reference to the funding source and any conditions or limitations associated.
    folder Primary support reason
    0 … 1
    prsb03-dataelement-12974link
    The primary support reason for social care.
    treetree folder Primary support reason record entry
    0 … *
    prsb03-dataelement-12975link
    This is a primary support reason record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
    treeblank treetree draft  Primary support reason
    0 … 1
    prsb03-dataelement-12976link
    The Primary Support Reason used to classify a person for National Reporting on Short and Long Term Services (SALT) e.g. Learning disability support, mental health support, physical supportFree text
    treeblank treetree draft  Active
    0 … 1
    prsb03-dataelement-13305link
    Flag to indicate whether the primary support reason is currently activeFlag: - Yes or No
    treeblank treetree draft  Start date
    0 … 1
    prsb03-dataelement-13306link
    The date a primary support reason was authorised as active.Date and time
    treeblank treetree draft  End date
    0 … 1
    prsb03-dataelement-13307link
    The end date of authorisation.Date and time
    folder Family history
    0 … 1
    prsb03-dataelement-251link
    Family history
    treetree folder Family history record entry
    0 … 1
    prsb03-dataelement-10653link
    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.
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-10153link
    The date the family history was taken.Date and time
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-10851link
    The location where the family history was taken.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13682link
    The coded value for locationNHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13683link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Relationship to person
    0 … 1
    prsb03-dataelement-10155link
    The relationship of the family member with the condition to the person.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13676link
    The coded value for relationship to personSNOMED CT: - <303071001 |Person in the family (person)|
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13677link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Family history
    0 … 1
    prsb03-dataelement-10151link
    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.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13678link
    The coded value for family historySNOMED CT:- <404684003 |Clinical finding (finding)| OR <243796009 |Situation with explicit context (situation)|
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13679link
    Free text field to be used if no coded text available
    treeblank treetree folder Condition or diagnosis
    0 … 1
    prsb03-dataelement-10152link
    The condition or diagnosis of the family member deemed to be significant to the care or health of the person.
    treeblank treeblank treetree cancelled  Coded value
    0 … 1
    prsb03-dataelement-13680link
    The coded value for condition or diagnosisSNOMED CT: - 999000771000000106 | Family history simple reference set (foundation metadata concept) |
    treeblank treeblank treetree cancelled  Free text
    0 … 1
    prsb03-dataelement-13681link
    Free text field to be used if no code is availableFree text
    treeblank treetree draft  Comment
    0 … 1
    prsb03-dataelement-10156link
    Any further textual comment.Free text
    folder Investigation results
    0 … 1
    prsb03-dataelement-257link
    Investigation results
    treetree folder Investigation results record entry
    0 … *
    prsb03-dataelement-10654link
    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.
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-10157link
    The date and time when the investigation was performedDate and time
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-10159link
    The location where the investigation took place.
    treeblank treeblank treetree draft  Coded location
    0 … 1
    prsb03-dataelement-13725link
    The coded value for locationNHS data dictionary : Organisation data service
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13726link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Investigation
    1 … 1 Mandatory
    prsb03-dataelement-10160link
    The investigation performed.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13525link
    The coded value for investigationSNOMED CT: - <71388002 |Procedure (procedure)|
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13526link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Investigation result
    0 … 1
    prsb03-dataelement-10161link
    For each investigation, the result of the investigation. This can include a report which may have results for multiple tests.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13527link
    The coded value for investigation resultsSNOMED CT:- <404684003 |Clinical finding (finding)| OR <243796009 |Situation with explicit context (situation)|
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13528link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Structured investigation result
    0 … 1
    prsb03-dataelement-12415link
    A structured set of information for each investigation result.
    treeblank treeblank treetree draft  Value
    0 … 1
    prsb03-dataelement-12416link
    The value of the investigation result.Numeric
    treeblank treeblank treetree draft  Units of measure
    0 … 1
    prsb03-dataelement-12417link
    The units of the investigation result.UCUM code
    treeblank treeblank treetree draft  Reference ranges
    0 … 1
    prsb03-dataelement-12418link
    The reference range for the investigation result.Free text
    treeblank treeblank treetree draft  Abnormal indicator
    0 … 1
    prsb03-dataelement-12419link
    Indicator if the investigation is abnormal.Abnormal or Normal
    folder Investigations requested
    0 … 1
    prsb03-dataelement-10730link
    Details of any investigations requested
    treetree folder Investigations requested record entry
    0 … *
    prsb03-dataelement-10731link
    This is an investigation requested record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-10732link
    The date the investigation was requested.Date and time
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-10736link
    The location where the investigation was requested.
    treeblank treetree folder Investigation requested
    1 … 1
    prsb03-dataelement-10733link
    The investigation that is requested. The investigation may refer to an individual test or a group of related tests or broader investigation required (so the investigator can determine the appropriate tests)
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13529link
    The coded value for Investigation requestedSNOMED CT: - <71388002 |Procedure (procedure)|
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13530link
    Free text field to be used if no code is availableFree text
    treeblank treetree draft  Status of request
    0 … 1
    prsb03-dataelement-10734link
    The status of the investigation request.Code : - draft | active | suspended | completed | entered-in-error | cancelled
    treeblank treetree draft  Reason for request
    0 … 1
    prsb03-dataelement-10737link
    An explanation or justification for why this investigation is being requested.Free text
    treeblank treetree draft  Request priority
    0 … 1
    prsb03-dataelement-10738link
    The urgency of the investigation requested.Code : - routine | urgent | asap | stat
    folder Examination findings
    0 … 1
    prsb03-dataelement-557link
    Examination findings
    treetree folder Examination findings record entry
    0 … *
    prsb03-dataelement-10662link
    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.
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-10462link
    The date the examination was performed.Date and time
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-10461link
    The location where the examination was performed.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13445link
    The coded value for locationNHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13446link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Examination findings
    0 … 1
    prsb03-dataelement-10458link
    The record of findings from the examinations performed.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13443link
    The coded value for examination findingsSNOMED CT : - ^1127601000000107 |Healthcare matters simple reference set (foundation metadata concept)|
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13444link
    Free text field to be used if no coded text available
    treeblank treetree folder Observations
    0 … 1
    prsb03-dataelement-10464link
    The record of essential physiological measurements, e.g., heart rate, blood pressure, temperature, pulse, height, weight, respiratory rate, oxygen saturation.
    treeblank treeblank treetree folder Observations record entry
    0 … *
    prsb03-dataelement-13866link
    This is an observations record entry. There may be 0 to many record entry/entries under a section. Each record entry is made up of a number of elements or data items.
    treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13447link
    The coded value for observationsSNOMED CT: - <363787002 | Observable entity (observable entity) |
    treeblank treeblank treeblank treetree draft  Value
    0 … 1
    prsb03-dataelement-13832link
    The measured value of the observationsEnumerated value e.g. numeric, natural numbers, mild, moderate
    treeblank treeblank treeblank treetree draft  Units of measure
    0 … 1
    prsb03-dataelement-13833link
    The units of measure for the observation.UCUM code
    treeblank treeblank treeblank treetree draft  Site
    0 … 1
    prsb03-dataelement-13848link
    The anatomical site at which the observation is takenSNOMED CT: - 442083009 | Anatomical or acquired body structure (body structure) |
    treeblank treeblank treeblank treetree draft  Interpretation
    0 … 1
    prsb03-dataelement-13843link
    The assessment made based on the result of the observation e.g high, lowFHIR value set: - Interpretation
    treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13448link
    Free text field to be used if no code is availableFree text
    folder Pregnancy status
    0 … 1
    prsb03-dataelement-10814link
    Pregnancy status of the person.
    treetree draft  Date
    0 … 1
    prsb03-dataelement-10812link
    The date the observation was recordedDate and time
    treetree folder Location
    0 … 1
    prsb03-dataelement-10855link
    The location where the pregnancy state details were recorded.
    treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13531link
    The coded value for location.NHS data dictionary: - Organisation data service
    treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13532link
    Free text field to be used if no code is availableFree text
    treetree draft  Pregnancy state
    0 … 1
    prsb03-dataelement-10815link
    A flag that indicates whether the person is pregnant.Flag : - Yes or No
    treetree draft  Expected delivery date
    0 … 1
    prsb03-dataelement-10813link
    The expected delivery date of the person.Date and time
    folder Assessments
    0 … 1
    prsb03-dataelement-262link
    Details of the person's assessments
    treetree folder Assessments record entry
    0 … *
    prsb03-dataelement-11664link
    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.
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-10763link
    The date the assessment was done.Date and time.
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-10764link
    The location where the assessment was done.ODS code or free text.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13570link
    The coded value for locationNHS data dictionary: - Organisation data service
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13571link
    Free text field to be used if no code is availableFree text
    treeblank treetree draft  Assessment type
    0 … 1
    prsb03-dataelement-10822link
    The type of the assessment e.g. social care needs assessment.Free text
    treeblank treetree draft  Assessment summary
    0 … 1
    prsb03-dataelement-10754link
    The summary of the assessmentFree text
    treeblank treetree folder Structured assessment
    0 … 1
    prsb03-dataelement-10655link
    Details of the structured assessment.
    treeblank treeblank treetree draft  Structured assessment name
    0 … 1
    prsb03-dataelement-11751link
    Structured assessment name e.g. New York Heart Failure, Glasgow Coma scale, Activities of Daily Living (ADL) etc.SNOMED CT
    treeblank treeblank treetree draft  Assessment score
    0 … 1
    prsb03-dataelement-10162link
    The structured assessment score.Free text.
    treeblank treeblank treetree draft  Assessment value
    0 … 1
    prsb03-dataelement-10163link
    The structured assessment value.Numeric
    treeblank treeblank treetree draft  Subscale score
    0 … *
    prsb03-dataelement-10169link
    The subscale score of the structured assessment.Free text.
    treeblank treeblank treetree draft  Subscale value
    0 … *
    prsb03-dataelement-10170link
    The subscale value of the structured assessment.Numeric
    treeblank treetree draft  Comment
    0 … 1
    prsb03-dataelement-10164link
    Supporting text may be given regarding the assessment.Free text
    folder Formulation
    0 … 1
    prsb03-dataelement-11666link
    Details of the person's formulation.
    treetree folder Formulation record entry
    0 … *
    prsb03-dataelement-11667link
    This is the formulation record entry. There may be 0 to many record entry/entries under a section. Each record entry is made up of a number of elements or data items.
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-11669link
    The date the formulation was made.Date and time.
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-11670link
    The location where the formulation was made.NHS data dictionary: - Organisation data service
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13572link
    The coded value for locationNHS data dictionary: - Organisation data service
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13573link
    Free text field to be used if no code is availableFree text
    treeblank treetree draft  Formulation
    1 … 1 Mandatory
    prsb03-dataelement-11668link
    An account, shared by a therapist and person, of the personal meaning and origins of a person’s difficulties. This is viewed in the context of multiple factors including relationships, social circumstances and life events and will indicate the most helpful way forward.Free text
    folder Risks
    0 … 1
    prsb03-dataelement-276link
    Details of any risks related to the person.
    treetree folder Risks to self
    0 … *
    prsb03-dataelement-10176link
    Details of the persons risk to self
    treeblank treetree draft  Start date of risk
    0 … 1
    prsb03-dataelement-11893link
    The start date of the risk.Date and time
    treeblank treetree draft  End date of risk
    0 … 1
    prsb03-dataelement-11894link
    The date the risk ended.Date and time
    treeblank treetree draft  Risk to self
    0 … 1
    prsb03-dataelement-13579link
    Risks the person poses to themselves, e.g. suicide, overdose, self-harm, self-neglect.SNOMED CT: - <281694009 |Finding of at risk (finding)|
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-11895link
    The location where the risk was identified.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13586link
    The coded value for locationNHS data dictionary : - Organisation service code
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13587link
    Free text field to be used if no code is availableFree text
    treetree folder Risks to others
    0 … *
    prsb03-dataelement-10177link
    Details of the person's risk to others
    treeblank treetree draft  Start date of risk
    0 … 1
    prsb03-dataelement-11913link
    The start date of the risk.Date and time
    treeblank treetree draft  End date of risk
    0 … 1
    prsb03-dataelement-11914link
    The date the risk ended.Date and time
    treeblank treetree draft  Risks to others
    0 … 1
    prsb03-dataelement-13580link
    Risks to professionals or others.SNOMED CT: - <<391155006 |At risk of harming others (finding)|
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-11915link
    The location where the risk to others was identified.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13588link
    The coded value for locationNHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13589link
    Free text field to be used if no code is availableFree text
    treetree folder Risk from others
    0 … *
    prsb03-dataelement-10178link
    Risks to the person from an identified individual e.g. family member etc.Free Text.
    treeblank treetree draft  Start date of risk
    0 … 1
    prsb03-dataelement-11933link
    The start date of the risk.Date and time
    treeblank treetree draft  End date of risk
    0 … 1
    prsb03-dataelement-11934link
    The date the risk ended.Date and time
    treeblank treetree draft  Risk from others
    0 … 1
    prsb03-dataelement-13581link
    Risks to the person from an identified individual e.g. family member etc.SNOMED CT: - <281694009 |Finding of at risk (finding)|
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-11935link
    The location where the risk from others was identified.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13590link
    The coded value for locationNHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13591link
    Free text field to be used if no code is availableFree text
    treetree folder Risk of accidents
    0 … *
    prsb03-dataelement-10751link
    Details of the risks the person poses to themselves from accidents.
    treeblank treetree draft  Start date of risk
    0 … 1
    prsb03-dataelement-11953link
    The start date of the risk.Date and time
    treeblank treetree draft  End date of risk
    0 … 1
    prsb03-dataelement-11954link
    The date the risk ended.Date and time
    treeblank treetree draft  Risk of accidents
    0 … 1
    prsb03-dataelement-13582link
    Risks the person poses to themselves from accidents.Free text
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-11955link
    The location where the risk of accidents was identified.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13592link
    The coded value for locationNHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13593link
    Free text field to be used if no coded text available
    treetree folder Other risks
    0 … *
    prsb03-dataelement-10802link
    Details of other risks, factors or behaviours relating to the person.
    treeblank treetree draft  Start date of risk
    0 … 1
    prsb03-dataelement-11973link
    The start date of the risk.Date and time
    treeblank treetree draft  End date of risk
    0 … 1
    prsb03-dataelement-11974link
    The date the risk ended.Date and time
    treeblank treetree draft  Other risks
    0 … 1
    prsb03-dataelement-13583link
    Other risks, factors or behaviours relating to the person.Free text
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-11975link
    The location where the other risks were identified.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13594link
    The coded value for locationNHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13595link
    Free text field to be used if no code is availableFree text
    folder Allergies and adverse reactions
    0 … 1
    prsb03-dataelement-282link
    Allergies and adverse reactions
    treetree folder Allergies and adverse reactions record entry
    0 … *
    prsb03-dataelement-10657link
    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.
    treeblank treetree draft  Type of reaction
    0 … 1
    prsb03-dataelement-10186link
    The type of reaction experienced by the person (allergic, adverse, intolerance)FHIR value set :- Allergy, Intolerance
    treeblank treetree folder Causative agent
    1 … 1
    prsb03-dataelement-10182link
    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”
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13441link
    The coded value for causative agent 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)
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13442link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Reaction details cluster
    0 … 1
    prsb03-dataelement-10658link
    Details of the reaction.
    treeblank treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-10190link
    The date that the reaction was identified.Date and time
    treeblank treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-10846link
    Details of where the allergy was identified. Linked to the date of the diagnosis by the professional.
    treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13439link
    The coded value for location.NHS data dictionary : - Organisation data service
    treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13440link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treetree folder Substance
    0 … 1
    prsb03-dataelement-11665link
    The substance, or a class of substances, that is considered to be responsible for the adverse reaction.
    treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13554link
    The coded value for substanceSNOMED CT : - <105590001 | Substance (substance) | or <373873005 | Pharmaceutical / biologic product (product) |
    treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13555link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treetree folder Description of reaction
    0 … 1
    prsb03-dataelement-10183link
    A description of the manifestation of the allergic or adverse reaction experienced by the person. For example, skin rash.
    treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13556link
    The coded value for description of reaction.SNOMED CT: - ^1127581000000103 |Health issues simple reference set|
    treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13557link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treetree draft  Onset date
    0 … 1
    prsb03-dataelement-13844link
    Date and time when manifestations showed e.g could be at home a few days earlier than the contactDate and time
    treeblank treeblank treetree folder Severity
    0 … 1
    prsb03-dataelement-10184link
    A description of the severity of the reaction.
    treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13558link
    The coded value for severityFHIR value set : - Severity
    treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13559link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treetree folder Certainty
    0 … 1
    prsb03-dataelement-10185link
    A description of the certainty that the stated causative agent caused the allergic or adverse reaction.
    treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13560link
    The coded value for certainty.FHIR value set : - Certainty
    treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13561link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treetree folder Route of exposure
    0 … 1
    prsb03-dataelement-13856link
    The route the person was exposed to the substance
    treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13857link
    The coded value for route of exposureSNOMED CT: - ^999000051000001100 |ePrescribing route of administration simple reference set|
    treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13858link
    Free text field to be used if no coded text available
    treeblank treeblank treetree draft  Comment
    0 … 1
    prsb03-dataelement-10189link
    Any additional comment or clarification about the adverse reaction.Free text
    treeblank treetree draft  Evidence
    0 … 1
    prsb03-dataelement-10187link
    Results of investigations that confirmed the certainty of the diagnosis. Examples might include results of skin prick allergy testsFree text
    treeblank treetree draft  Date first experienced
    0 … 1
    prsb03-dataelement-10188link
    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)Date and time
    treeblank treetree cancelled  Probability of recurrence
    0 … 1
    prsb03-dataelement-10191link
    Probability of the reaction (allergic, adverse, intolerant) occurring.Free text
    folder Medications and medical devices
    0 … 1
    prsb03-dataelement-636link
    Medications and medical devices
    treetree folder Medication item entry
    0 … *
    prsb03-dataelement-10663link
    All medications and devices that can be prescribed to be entered via this Medication item entry. Handles details of continuation / addition / amendment of admission medications.
    treeblank treetree folder Medication item cluster
    0 … 1
    prsb03-dataelement-10664link
    Medication item cluster
    treeblank treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-10843link
    The date on which the medication or medical device was prescribed.Date and time
    treeblank treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-10844link
    The location where the medication or the medical device was prescribed.
    treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13620link
    The coded value for locationNHS data dictionary : - Organisation data service
    treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13621link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treetree folder Medication name
    0 … 1
    prsb03-dataelement-10536link
    May be generic name or brand name.
    treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13622link
    The coded value for medication namedm+d:- any code from the VTM, VMP, AMP, VMPP and AMPP concept classes
    treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13623link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treetree folder Form
    0 … 1
    prsb03-dataelement-10537link
    The form of the medication e.g. capsule, drops, tablet, lotion etc.
    treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13624link
    The coded value for form.SNOMED CT: - ^999000781000001107 | National Health Service dictionary of medicines and devices dose form simple reference set (foundation metadata concept) |
    treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13625link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treetree folder Route
    0 … 1
    prsb03-dataelement-10538link
    The route by which the medication is administered e.g. oral, IM, IV
    treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13655link
    The coded value for routeSNOMED CT: - ^999000051000001100 |ePrescribing route of administration simple reference set (foundation metadata concept)|
    treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13656link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treetree folder Site
    0 … 1
    prsb03-dataelement-10540link
    The anatomical site at which the medication is to be administered.
    treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13657link
    The coded value for siteSNOMED CT: - <442083009 | Anatomical or acquired body structure (body structure) |
    treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13658link
    Free text field to be used when code is not availableFree text
    treeblank treeblank treetree folder Method
    0 … 1
    prsb03-dataelement-10541link
    The technique or method by which the medication is to be administered.
    treeblank treeblank treetree draft  Over the counter medication flag
    0 … 1
    prsb03-dataelement-13379link
    Indicates if the medication or device is acquired without a prescription i.e. got by the person over the counterFlag : - Yes or No
    treeblank treeblank treetree folder Structured dose direction cluster
    0 … 1
    prsb03-dataelement-11639link
    A structural representation of the elements carried by the dose syntax in 'parsable dose strength / timing' i.e. dose strength, dose timing, dose duration and maximum dose.
    treeblank treeblank treeblank treetree folder Structured dose amount
    0 … 1
    prsb03-dataelement-10554link
    A structural representation of dose amount, e.g. 20mg or 2 tablets. This element will generally only be used when persisting data within systems with 'parsable dose directions' being used to exchange the same information between systems. As per FHIR Dose Syntax Implementation Guidance (NHS Digital): https://simplifier.net/guide/DoseSyntaxImplementationGuidanceforFHIRR4/Home
    treeblank treeblank treeblank treetree draft  Structured dose timing
    0 … 1
    prsb03-dataelement-10555link
    A slot containing a structural, computable representation of dose timing and maximum dose. This element will generally only be used when persisting data within systems with 'parsable dose directions' being used to exchange the same information between systems. As per FHIR Dose Syntax Implementation Guidance (NHS Digital): https://simplifier.net/guide/DoseSyntaxImplementationGuidanceforFHIRR4/Home Numeric
    treeblank treeblank treeblank treetree draft  Dose direction duration
    0 … 1
    prsb03-dataelement-10548link
    Recommendation of the time period for which the medication should be continued, including direction not to discontinue. As per FHIR Dose Syntax Implementation Guidance (NHS Digital): https://simplifier.net/guide/DoseSyntaxImplementationGuidanceforFHIRR4/Home Numeric
    treeblank treeblank treeblank treetree draft  Dose directions description
    0 … 1
    prsb03-dataelement-10544link
    Describes the entire medication dosage and administration directions including dose quantity and medication frequency and optionally duration e.g. “1 tablet at night" or “2mg at 10pm”.Free text
    treeblank treeblank treetree draft  Additional instructions
    0 … 1
    prsb03-dataelement-10545link
    Allows for: requirements for adherence support, e.g. compliance aids, prompts and packaging requirements, additional information about specific medicines e.g. where specific brand required, person requirements, e.g. unable to swallow tablets.FHIR value set : - Additional instruction
    treeblank treeblank treetree folder Course details cluster
    0 … 1
    prsb03-dataelement-10561link
    Details of the overall course of medication.
    treeblank treeblank treeblank treetree draft  Course status
    0 … 1
    prsb03-dataelement-10666link
    The status of this prescription.FHIR value set : - Medication status
    treeblank treeblank treeblank treetree draft  Indication
    0 … 1
    prsb03-dataelement-10546link
    Reason for medication being prescribed, where known.Free text
    treeblank treeblank treeblank treetree draft  Start date/time
    0 … 1
    prsb03-dataelement-10667link
    The date and/or time that the medication course should begin.Date and time
    treeblank treeblank treeblank treetree draft  End date/time
    0 … 1
    prsb03-dataelement-10557link
    The date and/or time that the medication course should finish.Date and time
    treeblank treeblank treeblank treetree draft  Link to indication record
    0 … 1
    prsb03-dataelement-10668link
    A link to the record which contains the indication for this medication order.Free text with URL
    treeblank treeblank treeblank treetree draft  Comment/recommendation
    0 … 1
    prsb03-dataelement-10547link
    Suggestions about duration and/or review, ongoing monitoring requirements, advice on starting, discontinuing or changing medication. Additional comment or recommendation about the medication course e.g. 'Patient named supply', 'unlicensed medication', 'Foreign brand' or monitoring recommendationsFree text
    treeblank treeblank treetree folder Medication change summary cluster
    0 … 1
    prsb03-dataelement-10568link
    Records the changes made to medication.
    treeblank treeblank treeblank treetree draft  Status
    0 … 1
    prsb03-dataelement-10669link
    The nature of any change made to the medication.FHIR value set : Medication status
    treeblank treeblank treeblank treetree draft  Indication
    0 … 1
    prsb03-dataelement-10670link
    Reason for change in medication, e.g. sub-therapeutic dose, person intolerant. SNOMED CT:- ^1127601000000107 | Healthcare matters simple reference set (foundation metadata concept) |
    treeblank treeblank treeblank treetree draft  Date of change
    0 … 1
    prsb03-dataelement-10671link
    The date of the change - addition, or amendmentDate and time
    treeblank treeblank treeblank treetree draft  Description of amendment
    0 … 1
    prsb03-dataelement-10672link
    Where a change is made to the medication i.e. one drug stopped and another started or eg dose, frequency or route is changed.Free text
    treeblank treeblank treetree draft  Total dose daily quantity
    0 … 1
    prsb03-dataelement-10665link
    The total daily dose of this medication. This is helpful for estimating optimal adherence to dosing guidance. It may be computed from product/dose strength and frequency or entered manually.Free text
    treeblank treetree folder Medical devices entry
    0 … *
    prsb03-dataelement-10583link
    Medical devices
    treeblank treeblank treetree draft  Medical device
    0 … 1
    prsb03-dataelement-10673link
    Any medical device that isn't prescribed.Free text
    treeblank treeblank treetree draft  Comments
    0 … 1
    prsb03-dataelement-11280link
    Any information regarding the medical device.Free text
    treeblank treetree folder Medication discontinued entry
    0 … *
    prsb03-dataelement-10576link
    Medication discontinued entry
    treeblank treeblank treetree folder Name of discontinued medication
    0 … 1
    prsb03-dataelement-10577link
    The name of the medication or medical device being discontinued
    treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13659link
    The coded value for medication name dm+d:- any code from the VTM, VMP, AMP, VMPP and AMPP concept classes
    treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13660link
    Amount of vaccine administered.Free text
    treeblank treeblank treetree draft  Status
    0 … 1
    prsb03-dataelement-12472link
    The status of any change made to the medication. MUST CONTAIN STOPPED.FHIR value set: - Medication status
    treeblank treeblank treetree draft  Indication
    0 … 1
    prsb03-dataelement-10579link
    The clinical indication for any changes in medication status SNOMED CT:- ^1127601000000107 | Healthcare matters simple reference set (foundation metadata concept) |
    treeblank treeblank treetree draft  Date of change
    0 … 1
    prsb03-dataelement-10580link
    The date of the discontinuationDate and time
    treeblank treeblank treetree draft  Comment
    0 … 1
    prsb03-dataelement-10582link
    Any additional comment about the discontinuation or amendment.Free text
    folder Equipment and adaptations
    0 … 1
    prsb03-dataelement-12969link
    Details of equipment/asset (or modifications) that the Local Authority has provided to the patient.
    treetree folder Equipment record entry
    0 … 1
    prsb03-dataelement-12970link
    This is a equipment record entry. There may be 1 to many record entries under a section.
    treeblank treetree folder Equipment name
    0 … 1
    prsb03-dataelement-12971link
    The name of the equipment (e.g. 'Keysafe', 'Handrail' 'Lifeline Alarm', etc.)
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13780link
    The coded value for equipment nameSNOMED CT
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13782link
    Free text field to be used if no code is availableFree text
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-13066link

    The date the equipment was issued.Date and time
    treeblank treetree draft  Comment
    0 … 1
    prsb03-dataelement-12972link
    Any further details about the equipment, e.g. position of handrail(s) within the person's homeFree text
    folder Plan and requested actions
    0 … 1
    prsb03-dataelement-535link
    The details of planned investigations, procedures and treatment, and whether this plan has been agreed with the person or their legitimate representative.
    treetree folder Plan and requested actions record entry
    0 … *
    prsb03-dataelement-10661link
    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.
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-10445link
    The date on which the plan and requested actions were prepared.Date and time
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-10842link
    The location where the plan and requested actions were prepared.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13684link
    The coded value for locationNHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13685link
    Free text field to be used if no code is availableFree text
    treeblank treetree draft  Actions for professionals
    0 … 1
    prsb03-dataelement-10436link
    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.Free text
    treeblank treetree draft  Actions for person or their carer
    0 … 1
    prsb03-dataelement-10437link
    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.Free text
    treeblank treetree draft  Agreed with the person or their legitimate representative
    0 … 1
    prsb03-dataelement-10438link
    Indicates whether the person or their legitimate representative has agreed the entire plan or individual aspects of treatment, expected outcomes, risks and alternative treatments. A record of the agreement of the decisions made.Free text
    treeblank treetree draft  Outcome of plan and requested actions
    0 … *
    prsb03-dataelement-10950link
    The details of the outcome of the plan and requested actions.Free text.
    folder Care and support plan
    0 … 1
    prsb03-dataelement-508link
    This records the decisions reached during conversation between the individual and health and care professional about future plans and also records progress.
    treetree folder Strengths
    0 … *
    prsb03-dataelement-10419link
    Any strengths and assets the person has relating to their goals and hopes about their health and well-being.
    treetree folder Needs, concerns or problems
    0 … *
    prsb03-dataelement-10414link
    Details of the person needs, concerns or problems
    treeblank treetree folder Goals and hopes
    0 … *
    prsb03-dataelement-10413link
    The overall goals, hopes, aims or targets that the person has. Including anything that the person wants to achieve that relates to their future health and wellbeing. Each goal may include a description of why it is important to the person. Goals may also be ranked in order of importance or priority to the person.
    treeblank treeblank treetree folder Actions and activities
    0 … *
    prsb03-dataelement-10408link
    Actions or activities the person or others plan to take to achieve the person's goals and the resources required to do this.

    treeblank treeblank treeblank treetree folder What
    0 … 1
    prsb03-dataelement-10675link
    What the action is and how it is to be carried out?
    treeblank treeblank treeblank treetree folder Who
    0 … 1
    prsb03-dataelement-10676link
    Name and role (e.g. person, carer, GP, OT, etc.) of the person, or a team, carrying out the proposed action, and, if relevant where action should take place.
    treeblank treeblank treeblank treetree draft  When
    0 … 1
    prsb03-dataelement-10677link
    Planned date, time, or interval, as relevantDate and time
    treeblank treeblank treeblank treetree draft  Suggested strategies
    0 … 1
    prsb03-dataelement-10678link
    Suggested strategies for potential problems.Free text.
    treeblank treeblank treeblank treetree folder Status
    0 … 1
    prsb03-dataelement-10679link
    The status of the action or activity e.g. in progress, done, refused
    treeblank treeblank treeblank treetree draft  Confidence
    0 … 1
    prsb03-dataelement-10680link
    How confident the person feels to carry out the action associated to the goal.Numeric score 1 - 10
    treeblank treeblank treeblank treetree draft  Date last updated
    0 … 1
    prsb03-dataelement-10682link
    Date when action/activity record was last updatedDate and time
    treeblank treeblank treeblank treetree draft  Review date
    0 … 1
    prsb03-dataelement-10683link
    When the action evaluation needs to be reviewed. SNOMED CT tag : - 425268008 | Review of care plan (procedure) |Date and time.
    treeblank treeblank treeblank treetree folder Stage goal
    0 … 1
    prsb03-dataelement-10674link
    Details of the person's stage goals
    treeblank treeblank treeblank treeblank treetree folder Outcome
    0 … 1
    prsb03-dataelement-10681link
    The outcome of the stage goal
    treeblank treeblank treetree folder Outcomes
    0 … *
    prsb03-dataelement-10416link
    Outcomes of each of the person’s goals, aims and targets. Includes comments recorded by the person, date and status.
    treetree folder Agreed with person or legitimate representative
    0 … 1
    prsb03-dataelement-10409link
    Indicates whether the plan was discussed and agreed with the person or legitimate representative.
    treetree folder Care funding source
    0 … 1
    prsb03-dataelement-10410link
    A reference to the funding source and any conditions or limitations associated.
    treetree draft  Date this plan was last updated
    0 … 1
    prsb03-dataelement-10412link
    This is a record of the date that this care and support plan was last updated.Date and time
    treetree draft  Other care planning documents
    0 … *
    prsb03-dataelement-10415link
    Reference other care planning documents, including the type, location and date.

    This may include condition-specific plans, advance care plans, end of life care plan, etc.Free text.
    treetree draft  Planned review date/interval
    0 … 1
    prsb03-dataelement-10417link
    This is the date/interval when this information will next be reviewed. SNOMED CT tag : - 425268008 | Review of care plan (procedure) |Date and time
    treetree folder Responsibility for review
    0 … 1
    prsb03-dataelement-10418link
    This is a record of who has responsibility for arranging review of this information.
    treetree folder Location
    0 … 1
    prsb03-dataelement-12044link
    The location where the care and support plan was prepared.
    treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13665link
    The coded value for locationNHS data dictionary: - Organisation data service
    treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13666link
    Free text field to be used if no coded text available
    folder Contingency/safety plans
    0 … *
    prsb03-dataelement-469link
    These are the things to do and people to contact, should an individual’s health or other circumstances get worse for safety.
    treetree folder Trigger factors
    0 … *
    prsb03-dataelement-10375link
    Signs to watch out for that may indicate a significant change in health or other circumstances e.g. feeling agitated
    treetree folder Contingency plan name
    0 … 1
    prsb03-dataelement-10371link
    When the action evaluation needs to be reviewed. 
    treetree folder What should happen
    0 … *
    prsb03-dataelement-10376link
    Guidance on specific actions or interventions that may be required or should be avoided in specific situations. This may include circumstances where action needs to be taken if a carer is unable to care for the person. A statement of suggested actions. Usually expressed as: in the event of X do Y.
    treetree folder Who should be contacted
    0 … *
    prsb03-dataelement-10377link
    Who should be contacted in the event of significant problems or deterioration in health or wellbeing. e.g. name, role and contact details.
    treetree folder Agreed with person or legitimate representative
    0 … 1
    prsb03-dataelement-10369link
    Indicates whether the plan was discussed and agreed with the person or legitimate representative.
    treetree draft  Date this plan was last updated
    0 … 1
    prsb03-dataelement-10372link
    The date that this contingency plan was last updated.Date and time
    treetree draft  Planned review date/interval
    0 … 1
    prsb03-dataelement-10373link
    This is the date/interval when this contingency plan will next be reviewed. SNOMED CT tag : - 425268008 | Review of care plan (procedure) |Date and time
    treetree folder Responsibility for review
    0 … 1
    prsb03-dataelement-10374link
    This is who has responsibility for arranging review of this information.
    treetree folder Coping strategies
    0 … *
    prsb03-dataelement-13850link
    Details of coping strategies used
    treeblank treetree draft  Coping strategy
    0 … 1
    prsb03-dataelement-13851link
    The coping strategies are defined as thoughts and behaviours that people use to manage the internal and external demands of situations that are appraised as stressful. This should also include a record of any tools used to carry out the coping strategy.Free text
    treeblank treetree draft  Start date
    0 … 1
    prsb03-dataelement-13852link
    The date when the coping strategy startedDate and time
    treeblank treetree draft  End date
    0 … 1
    prsb03-dataelement-13853link
    The date when the coping strategy endedDate and time
    treetree folder Relapse indicators / early warning signs
    0 … *
    prsb03-dataelement-13854link
    Details of the relapse indicators for the person. These may also be called 'early warning signs'
    treetree folder Advance statement
    0 … 1
    prsb03-dataelement-10777link
    Written requests and preferences made by a person with capacity conveying their wishes, beliefs and values for their future care should they lose capacity.
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-12267link
    The date when the advanced statements was made.Date and time
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-12268link
    The location where the advanced statement was made.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13698link
    The coded value for locationNHS data dictionary: - Organisation data service
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13699link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Advance statement
    0 … 1
    prsb03-dataelement-13695link
    Does the person have an advance statement.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13696link
    The coded value for advance statementSNOMED CT: - 816281000000101 | Has advance statement (Mental Capacity Act 2005) (finding) |
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13697link
    Free text field to be used if no code is availableFree text
    treeblank treetree draft  Location of document
    0 … 1
    prsb03-dataelement-13760link
    The location of where the advanced statement is held.Free text or URL
    treetree draft  Anticipatory medicines/equipment
    0 … *
    prsb03-dataelement-10370link
    Medicines or equipment available that may be required in specific situations and their location. A statement regarding the availability or location of the anticipatory medicines/equipment. SNOMED CT Tag : - 871021000000106 | Prescription of palliative care anticipatory medication (procedure) |Free text
    treetree folder Location
    0 … 1
    prsb03-dataelement-12079link
    The location where the contingency plan was prepared.
    treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13667link
    The coded value for locationNHS data dictionary : - Organisation data service
    treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13668link
    Free text field to be used if no code is availableFree text
    folder Additional support plans
    0 … *
    prsb03-dataelement-502link
    Additional support plans
    treetree folder Additional support plan name
    0 … 1
    prsb03-dataelement-10402link
    The name of the particular additional supporting plan, e.g. dieticians plan, wound management plan, discharge management plan and behaviour support plan.
    treetree draft  Additional support plan content
    0 … 1
    prsb03-dataelement-10403link
    This is the content of any additional care and support plan which the person and/or care professional consider should be shared with others providing care and support. May be structured in different ways, e.g. tables, diagrams, images. This is the content of any additional care and support plan which the individual and/or care professional consider should be shared with others providing care and support. It should be structured as recommended for the care and support plan and if contains additional detail, it may be referenced here.Free text
    treetree draft  Planned review date/interval
    0 … 1
    prsb03-dataelement-10405link
    This is the date/interval when this information will next be reviewed. SNOMED CT tag : - 425268008 | Review of care plan (procedure) |Date and time
    treetree folder Responsibility for review
    0 … 1
    prsb03-dataelement-10406link
    This is a record of who has responsibility for arranging review of this information. Should include their name, role and contact details.
    treetree draft  Date this plan was last updated
    0 … 1
    prsb03-dataelement-10407link
    This is a record of the date that this information was last updated.Date and time
    treetree folder Location
    0 … 1
    prsb03-dataelement-12080link
    The location where the additional support plan was prepared.ODS code or free text
    treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13722link
    The coded value for locationNHS data dictionary:- Organisation data service
    treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13723link
    Free text field to be used if no code is availableFree text
    folder End of life care
    0 … 1
    prsb03-dataelement-10743link
    Information relating to end of life care.

    N.B. This is not an end of life care plan but contains information that would be found in an end of life care plan.
    treetree folder Cardio-pulmonary resuscitation (CPR) decision
    0 … 1
    prsb03-dataelement-10771link
    Whether a decision has been made, the decision, who made the decision, the date of decision, date for review and location of documentation. Where the person or their family member/carer have not been informed of the clinical decision please state the reason why.
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-12210link
    The date when the cardio-pulmonary resuscitation decision was made.Date and time.
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-12211link
    The location where the cardio-pulmonary resuscitation decision was made.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13689link
    The coded value for locationNHS data dictionary: - Organisation data service
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13690link
    Free text field to be used if no coded text available
    treeblank treetree folder Cardio-pulmonary resuscitation (CPR) decision
    0 … 1
    prsb03-dataelement-13686link
    The cardio-pulmonary resuscitation (CPR) decision.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13687link
    The coded value for CPR decision or DNACPRSNOMED CT: - 450475007 | For cardiopulmonary resuscitation (finding) |, 450476008 | Not for cardiopulmonary resuscitation (finding) |
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13688link
    Free text field to be used if no code is availableFree text
    treeblank treetree draft  Date for review
    0 … 1
    prsb03-dataelement-13705link
    The date for review of CPR decision.Date and time
    treeblank treetree draft  Location of document
    0 … 1
    prsb03-dataelement-13706link
    The location of the CPR decision documentFree text or URL
    treetree folder Estimated prognosis
    0 … 1
    prsb03-dataelement-10745link
    Details of the persons estimated prognosis
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-12229link
    The date when the estimated prognosis was made.Date and time
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-12230link
    The location where the estimated prognosis was made.ODS code or free text
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13703link
    The coded value for locationNHS data dictionary: - Organisation data service
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13704link
    Free text field to be used if no coded text available
    treeblank treetree draft  Estimated prognosis
    0 … 1
    prsb03-dataelement-13691link
    Where a person is terminally ill this is a clinical judgment indicating the anticipated period of time until death e.g. last days, weeks, months or year of life.Free text
    treetree folder Awareness of prognosis
    0 … 1
    prsb03-dataelement-10775link
    Details of the persons awareness of prognosis
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-12248link
    The date when the assessment of the level of awareness of the prognosis was made.Date and time
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-12249link
    The location where the assessment of the level of awareness of the prognosis was made.ODS code and free text
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13693link
    The coded value for locationNHS data dictionary: - Organisation data service
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13694link
    Free text field to be used if no code is availableFree text
    treeblank treetree draft  Awareness of prognosis
    0 … 1
    prsb03-dataelement-13692link
    Description of the level of awareness the person and or their carer/family has regarding their estimated prognosis.Free text
    treetree draft  Priorities of care
    0 … *
    prsb03-dataelement-10201link
    The priorities agreed between the person and their health/care team, where the person has capacity: To get better; please consider all treatment to prolong life. To achieve a balance between getting better and ensuring good quality of life; please consider selected treatments. Comfort; please consider all treatments aimed at symptom control.Free text
    treetree folder Anticipatory actions
    0 … *
    prsb03-dataelement-10786link
    Details of the person's anticipatory actions
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-12286link
    The date when the anticipatory actions were identified.Date and time
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-12287link
    The location where the anticipatory actions were identified.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13701link
    The coded value for locationNHS data dictionary: - Organisation data service
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13702link
    Free text field to be used if no coded text available
    treeblank treetree draft  Anticipatory actions
    0 … 1
    prsb03-dataelement-13700link
    Guidance on specific interventions or actions that may be required or should be avoided in specific situations. A statement of anticipatory actions. Usually expressed as: in the event of X do Y.Free text
    treetree folder Anticipatory medicines/equipment
    0 … *
    prsb03-dataelement-10785link
    Details of the persons availability or location regarding their anticipatory medicines/equipment.
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-12305link
    The date when the statement regarding anticipatory medicines/equipment was made.Date and time
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-12306link
    The location where the statement regarding anticipatory medicines/equipment was made.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13708link
    The coded value for locationNHS data dictionary: - Organisation data service
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13709link
    Free text field to be used if no coded text available
    treeblank treetree draft  Anticipatory medicines/equipment
    0 … 1
    prsb03-dataelement-13707link
    A statement regarding the availability or location of the anticipatory medicines/equipment.Free text
    treetree folder Preferred place of death
    0 … 1
    prsb03-dataelement-10780link
    Details of the person's preferred place of death
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-12324link
    The date when the preferred place of death was identified.Date and time
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-12325link
    The location where the preferred place of death was identified.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13713link
    The coded value for locationNHS data dictionary: - Organisation data service
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13714link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Preferred place of death 1st
    0 … 1
    prsb03-dataelement-13710link
    The preferences that a person has identified as their preferred place to die.
    treeblank treeblank treetree draft  Name of the place
    0 … 1
    prsb03-dataelement-13711link
    The name of the preferred place of deathFree text
    treeblank treeblank treetree draft  Type of place
    0 … 1
    prsb03-dataelement-13712link
    The type of preferred place of deathSCC11580 code : - 10: Hospital (Acute/Community/Other)20: Private residence21: Patient's own home22: Other private residence (eg relatives home, carers home)30: Hospice (inpatient specialist palliative care)40: Care Home50: Other (free text eg secure and detained settings)517111000000103, Preferred place of death: patient unable to express preference 517131000000106, Preferred place of death: discussion not appropriate766391000000108, Preferred place of death: patient declined discussion517161000000101, Preferred place of death: patient undecided
    treeblank treetree folder Preferred place of death 2nd
    0 … 1
    prsb03-dataelement-13716link
    The preferences that a person has identified as their preferred place to die.
    treeblank treeblank treetree draft  Name of the place
    0 … 1
    prsb03-dataelement-13717link
    The name of the preferred place of deathFree text
    treeblank treeblank treetree draft  Type of place
    0 … 1
    prsb03-dataelement-13718link
    The type of preferred place of deathSCC11580 code : - 10: Hospital (Acute/Community/Other)20: Private residence21: Patient's own home22: Other private residence (eg relatives home, carers home)30: Hospice (inpatient specialist palliative care)40: Care Home50: Other (free text eg secure and detained settings)517111000000103, Preferred place of death: patient unable to express preference 517131000000106, Preferred place of death: discussion not appropriate766391000000108, Preferred place of death: patient declined discussion517161000000101, Preferred place of death: patient undecided
    treetree folder Preferred place of care
    0 … 1
    prsb03-dataelement-10781link
    Details of the persons preferred place of care
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-12362link
    The date when the preferred place of care was identified.Date and time
    treeblank treetree folder Location
    0 … 1
    prsb03-dataelement-12363link
    The location where the preferred place of care was identified.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13720link
    The coded value for locationNHS data dictionary: - Organisation data service
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13721link
    Free text field to be used if no code is availableFree text
    treeblank treetree draft  Preferred place of care
    0 … 1
    prsb03-dataelement-13719link
    The preferences that the person has identified as their preferred place to receive care.Free text
    folder Documents (including correspondence, audio and images)
    0 … 1
    prsb03-dataelement-10820link
    Details about documents related to the person.
    treetree folder Documents
    0 … *
    prsb03-dataelement-11259link
    This is the documents record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-10943link
    The date and time the document was created.Date and time
    treeblank treetree folder Performing professional
    0 … 1
    prsb03-dataelement-12422link
    The professional who authored the document.Free text.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-12423link
    The name of the professional.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-12424link
    The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-12425link
    The grade of the professional.Free text
    treeblank treeblank treetree draft  Speciality
    0 … 1
    prsb03-dataelement-12426link
    The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-12427link
    Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-12428link
    The name of the organisation the professional works for.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-12429link
    Contact details of the professionalNHS data dictionary - UK phone number
    treeblank treetree draft  Documentation location
    0 … 1
    prsb03-dataelement-10946link
    The location of the documentFree text or URL
    treeblank treetree draft  Confidentiality
    0 … 1
    prsb03-dataelement-10942link
    The code specifying the level of confidentiality of the document. FHIR value set : - Confidentiality
    treeblank treetree draft  Class
    0 … 1
    prsb03-dataelement-10940link
    The document type e.g. report, summary, images, treatment plan, patient preferences, workflowFree text.
    treeblank treetree draft  Document title
    0 … 1
    prsb03-dataelement-10944link
    The title of the document.Free text
    treeblank treetree draft  Document name
    0 … 1
    prsb03-dataelement-10945link
    The name of the document. This should align to the PRSB document naming standard. Where the document is a KOS document this field (designated typeCode) is used to carry the DICOM Imaging procedure: This attribute shall be populated by the XDS-I Imaging Document Source from a code in the Procedure Code Sequence (0008,1032) of the performed procedure with which the document is associated. Values may be found in a suitable DICOM browserSNOMED CT: - As per the https://theprsb.org/wp-content/uploads/2018/11/Clinical-document-indexing-standards_NHS-Scotland.pdf
    treeblank treetree draft  Document MIME type
    0 … 1
    prsb03-dataelement-10949link
    MIME type of the document e.g. application, pdf, audio, jpegFree text
    treeblank treetree folder Person completing record
    0 … 1
    prsb03-dataelement-12430link
    Details of the person completing the record.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-12431link
    The name of the person completing the record.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-12432link
    The organisational role of the person completing record.FHIR value set :- SDSjobrole
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-12433link
    The grade of the person completing the record.Free text.
    treeblank treeblank treetree draft  Specialty
    0 … 1
    prsb03-dataelement-12434link
    The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-12435link
    The organisation the person completing the record works for. NHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Professional identifier
    0 … 1
    prsb03-dataelement-12436link
    Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
    treeblank treeblank treetree draft  Date completed
    0 … 1
    prsb03-dataelement-12437link
    The date and time the record was completed.Date and time.
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-12438link
    Contact details of the person completing the record.
    NHS data dictionary : - UK telephone number
    treeblank treetree folder Service
    0 … 1
    prsb03-dataelement-11163link
    The high level imaging speciality code e.g. (R-3027B, SRT, “Radiology”)SNOMED CT or free text 999000381000000107 |Correspondence care setting type simple reference set (foundation metadata concept)|
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13749link
    The coded value for serviceSNOMED CT :- 1127531000000102 |Services simple reference set (foundation metadata concept)|
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13750link
    Free text field to be used if no code is availableFree text
    treeblank treetree draft  Comments
    0 … 1
    prsb03-dataelement-10941link
    Comments associated with the document.Free text
    treeblank treetree folder Additional information required for images.
    0 … 1
    prsb03-dataelement-12449link
    Additional information required for images.
    treeblank treeblank treetree draft  Image procedure
    0 … 1
    prsb03-dataelement-12450link
    The procedure used to capture the imageFree text Using DICOM code set https://dicom.innolitics.com/ciods
    treeblank treeblank treetree draft  Image procedure date
    0 … 1
    prsb03-dataelement-12451link
    The date and time the image procedure was performed.Date and time
    treeblank treeblank treetree folder Images
    0 … 1
    prsb03-dataelement-11158link
    treeblank treeblank treeblank treetree draft  Image capture date
    0 … 1
    prsb03-dataelement-11159link
    The date and time when the image was captured.Date and time
    treeblank treeblank treeblank treetree draft  Image ID
    0 … 1
    prsb03-dataelement-12460link
    A unique image identifier generated by the system.Free text
    treeblank treeblank treeblank treetree draft  Image location
    0 … 1
    prsb03-dataelement-12461link
    The URL for the imageFree text
    treeblank treeblank treetree draft  Format code
    0 … 1
    prsb03-dataelement-11161link
    The format code of the document which provides information on how to display the document.Free text
    treeblank treeblank treetree draft  Event code list
    0 … 1
    prsb03-dataelement-11160link
    The type of image (acquisition modality) and the anatomical site imaged.DICOM code
    treeblank treeblank treetree draft  Comments
    0 … 1
    prsb03-dataelement-12471link
    Comments associated with the imagingFree text
    cancelled rotate Core information standard (slim down view)
    prsb03-transaction-161link
    Version / effective date 0.1 - 2020‑09‑09 00:03:01    
    Description Core information standard with no meta data
    Actor
    stationary (organization) Shared care record
    Associations
    Contained concepts
    Concept Card/Conf Id
    folder Person demographics
    1 … 1 Mandatory
    prsb03-dataelement-10868link
    The person's details and contact information.
    treetree folder Person name
    1 … 1 Mandatory
    prsb03-dataelement-10869link
    Details of the person's name
    treeblank treetree draft  Person preferred name
    0 … 1
    prsb03-dataelement-10870link
    The name by which a person wishes to be addressed. The preferred name volunteered by the person or a preferred name given by PDS that the person has asked to be called by.NHS data dictionary: - Person full name
    treetree draft  Date of birth
    1 … 1 Mandatory
    prsb03-dataelement-10871link
    The date of birth of the person.NHS data dictionary:- Person birth date
    treetree draft  Gender
    0 … 1
    prsb03-dataelement-10872link
    The person's stated gender.NHS data dictionary :- Person stated gender code
    treetree draft  Person alias
    0 … *
    prsb03-dataelement-10873link
    Other name(s) associated with the person.Free text
    treetree draft  Ethnicity
    0 … 1
    prsb03-dataelement-10874link
    The ethnicity of the person as specified by the person.NHS data dictionary :- Ethnic category
    treetree draft  Religion
    0 … 1
    prsb03-dataelement-10876link
    The religious affiliation as specified by the person. SNOMED_CT:- Religion
    treetree draft  Sex
    0 … 1
    prsb03-dataelement-10877link
    The person’s phenotypic sex. Determines how the person will be treated clinically.NHS data dictionary: - person phenotypic sex
    treetree draft  NHS number
    0 … 1
    prsb03-dataelement-10879link
    The unique identifier for a person within the NHS in England and Wales.NHS data dictionary:- NHS number
    treetree draft  Other identifier
    0 … *
    prsb03-dataelement-10880link
    Country specific or local identifier, e.g. Community Health Index (CHI) in Scotland. NHS data dictionary: - Local patient identifier(extended), Health and care number (NI only), Community health index number (Scotland only)
    treetree folder Person's address
    1 … * Mandatory
    prsb03-dataelement-10881link
    Person’s usual place of residence, and where relevant temporary and correspondence addresses.
    treeblank treetree draft  Address line 1
    1 … 1 Mandatory
    prsb03-dataelement-13082link
    Person's first line of address. NHS data dictionary :-  Address line 1
    treeblank treetree draft  Address line 2
    0 … 1
    prsb03-dataelement-13083link
    Person's second line of address. NHS data dictionary :- Address line 2
    treeblank treetree draft  Address line 3
    0 … 1
    prsb03-dataelement-13084link
    Person's third line of address. NHS data dictionary : - Address line 3
    treeblank treetree draft  Address line 4
    0 … 1
    prsb03-dataelement-13085link
    Person's fourth line of address. NHS data dictionary : - Address line 4
    treeblank treetree draft  Address line 5
    0 … 1
    prsb03-dataelement-13086link
    Person's fifth line of address.NHS data dictionary : - Address line 5
    treeblank treetree draft  Postcode
    1 … 1 Mandatory
    prsb03-dataelement-13087link
    The person's postcode.NHS data dictionary :- Postcode of usual address
    treetree folder Person's contact details
    0 … *
    prsb03-dataelement-13804link
    Details of the person's contact information.
    treeblank treetree draft  Preferred contact method
    0 … 1
    prsb03-dataelement-10886link
    Preferred contact method, e.g. email, letter, phone, text message etc.NHS data dictionary :- Communication contact method
    treeblank treetree folder Person's telephone number details
    0 … *
    prsb03-dataelement-10883link
    The person's telephone number details
    treeblank treetree folder Person's email address details
    0 … *
    prsb03-dataelement-13807link
    Details of the person's email address
    treeblank treeblank treetree draft  Person's email address
    0 … 1
    prsb03-dataelement-10882link
    Email address of the person.NHS data dictionary :- Contact email address
    treetree draft  Place of birth
    0 … 1
    prsb03-dataelement-10884link
    The country of birth of the person.NHS data dictionary :- Country code (birth)
    treetree draft  Marital status
    0 … 1
    prsb03-dataelement-10885link
    An indicator to identify the legal marital status of the person.NHS data dictionary :- Person marital status
    treetree folder Organ and tissue donation
    0 … 1
    prsb03-dataelement-10430link
    Whether the person has given consent for organ and/or tissue donation or opted out of automatic donation where applicable. This is information provided by the national register.Flag
    folder GP practice
    1 … 1 Mandatory
    prsb03-dataelement-101link
    Details of the person's GP practice.
    treetree folder GP practice record entry
    0 … *
    prsb03-dataelement-10643link
    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
    treeblank treetree draft  GP name
    0 … 1
    prsb03-dataelement-10003link
    The name of the person's GP. If the person is registered with a GP practice, their usual GP name will be something volunteered by the person or their representative.Free text
    treeblank treetree draft  GP practice details
    0 … 1
    prsb03-dataelement-10002link
    Name and address of the person's registered GP practice Registered GP practice details are available from the Person Demographics Service (PDS), or volunteered from the person or their representative. Include details of the practice name and address.Free text
    treeblank treetree draft  GP practice identifier
    1 … 1 Mandatory
    prsb03-dataelement-10001link
    The identifier of the registered GP practice. NHS data dictionary : - General medical practice code (patient registration)
    treeblank treetree draft  GP opt out indicator
    0 … 1
    prsb03-dataelement-10004link
    Indication that the person has opted out of registering with a GP.SNOMED CT : - 1092961000000104 |Does not wish to register with an NHS general practitioner (finding)| OR 1092941000000100 |Family using private general practitioner (finding)|
    folder About me
    0 … 1
    prsb03-dataelement-466link
    About me
    treetree folder What is most important to me
    0 … 1
    prsb03-dataelement-12964link
    A description of what is most important to you.
    treetree folder People who are important to me
    0 … 1
    prsb03-dataelement-13009link
    Details of who is important to you and why. 
    treetree folder How I communicate and how to communicate with me
    0 … 1
    prsb03-dataelement-13006link
    A description of how you communicate normally. 
    treetree folder My wellness
    0 … 1
    prsb03-dataelement-13005link
    A description covering what you are able to do, how you engage with others and how you feel on a typical day through to on a day when you are unwell or really unwell.
    treetree folder Please do and please don't
    0 … 1
    prsb03-dataelement-13008link
    A description of things you want someone supporting you to do (or not to do). 
    treetree folder How and when to support me
    0 … 1
    prsb03-dataelement-13007link
    A description of how and when you want someone caring for you to support you.
    treetree folder Also worth knowing about me
    0 … 1
    prsb03-dataelement-13094link
    A description of what is also worth knowing about you for people caring or supporting you. 
    treetree folder About me
    0 … 1
    prsb03-dataelement-10366link
    This is a record of the things that a person feels it is important to communicate about their needs, strengths, values, concerns and preferences to others providing support and care.
    folder Individual requirements
    0 … 1
    prsb03-dataelement-160link
    The individual requirements of the person.
    treetree folder Reasonable adjustment
    0 … 1
    prsb03-dataelement-12991link
    A record of reasonable adjustments that must be provided by the service to comply with the Equality Act 2010.
    treeblank treetree folder Reasonable adjustment record entry
    0 … 1
    prsb03-dataelement-13061link
    This is a reasonable adjustment record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items
    treeblank treeblank treetree folder Reasonable adjustment
    0 … 1
    prsb03-dataelement-13017link
    The reasonable adjustment required e.g. requires specific contact method, requires communication professional
    treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13505link
    The coded value for reasonable adjustmentSNOMED CT : - Accessible information standard^999002121000000109 |Accessible information - communication support simple reference set (foundation metadata concept)|^999002151000000104 |Accessible information - requires communication professional simple reference set (foundation metadata concept)|^999002131000000106 |Accessible information - requires specific contact method simple reference set (foundation metadata concept)|^999002141000000102 |Accessible information - requires specific information format simple reference set (foundation metadata concept)|Refsets for other categories in development
    treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13506link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treetree draft  Reasonable adjustment additional detail
    0 … 1
    prsb03-dataelement-13018link
    Further detail about the support required and the consequence of not providing it.Free text
    treetree folder Impairment
    0 … 1
    prsb03-dataelement-13001link
    A record of any impairments for the person relating to reasonable adjustments.
    treeblank treetree folder Impairment record entry
    0 … 1
    prsb03-dataelement-13062link
    This is an impairment record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items
    treeblank treeblank treetree folder Impairment category
    0 … 1
    prsb03-dataelement-13022link
    The category of the impairment e.g. Autism, Dementia, Physical disability, Sensory disability - such as sight or hearing, Long-term condition
    treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13507link
    The coded value for impairment.SNOMED CT
    treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13508link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treetree draft  Impairment additional detail
    0 … 1
    prsb03-dataelement-13023link

    Description of what the person can do with the impairment, what they want to be able to do and how they should be supported to do it and what the consequences are of not providing the support.
    Where there is a sensory disability include sensory processing difficulties (e.g. affects to balance and movement, oversensitive, under-sensitive).
    Free text
    treetree folder Cognition
    0 … *
    prsb03-dataelement-10066link
    Details of the persons cognitive impairment.
    treeblank treetree draft  Cognition
    0 … 1
    prsb03-dataelement-13669link
    The cognitive impairment to be considered when communicating with the person, child or their primary carer.Free text
    treetree folder Mobility
    0 … *
    prsb03-dataelement-10067link
    Details of the person's mobility needs.
    treeblank treetree folder Mobility needs
    0 … 1
    prsb03-dataelement-13670link
    The mobility needs of the person that allows movement between two spaces and achieves participation and a degree of independence.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13671link
    The coded value for mobility needsSNOMED CT: - ^999002551000000108 |Mobility findings simple reference set (foundation metadata concept)|
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13672link
    Free text field to be used if no code is availableFree text
    treetree folder Other individual requirements
    0 … *
    prsb03-dataelement-10835link
    Details of any other individual requirements the person may have
    treeblank treetree draft  Other individual requirement
    0 … 1
    prsb03-dataelement-13673link
    Other individual requirements that a person may have.Free text
    folder Alerts
    0 … 1
    prsb03-dataelement-10741link
    Details of alerts.
    treetree folder Alerts record entry
    0 … *
    prsb03-dataelement-10916link
    This is an alerts record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items
    treeblank treetree draft  Alert
    0 … 1
    prsb03-dataelement-10742link
    Any significant information meriting a specific and highly visible warning to any user (e.g. metallic implant, potential dangerous pet).Free text
    folder Legal information
    0 … 1
    prsb03-dataelement-520link
    The legal information relating to the person.
    treetree folder Consent for information sharing
    0 … 1
    prsb03-dataelement-10421link
    Details of the person's consent for information sharing
    treeblank treetree draft  Consent for information sharing
    0 … 1
    prsb03-dataelement-13575link
    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.Free text
    treetree folder Consent relating to child
    0 … *
    prsb03-dataelement-10422link
    Details of the person's consent relating to child
    treeblank treetree draft  Consent relating to child
    0 … 1
    prsb03-dataelement-13576link
    The person with parental responsibility or appointed guardian where a child lacks competency. Consideration of age and competency, applying Gillick competency or Fraser guidelines.Free text
    treetree folder Mental capacity assessment
    0 … *
    prsb03-dataelement-10424link
    Details of the persons mental capacity assessment
    treeblank treetree cancelled  Mental capacity assessment
    0 … 1
    prsb03-dataelement-13090link
    Record where a person diagnosed with a mental disorder is formally detained under the Mental Health Act or equivalent, including the section number and start date, start time and end date. If person subject to Community Treatment Order or Conditional Discharge (or equivalent) record here.NHS data dictionary : - Mental health act legal status classification code
    treetree folder Lasting power of attorney for health and welfare or court-appointed deputy (or equivalent)
    0 … 1
    prsb03-dataelement-10425link
    Details of the person's LPA record or equivalent
    treeblank treetree folder Lasting power of attorney for health and welfare or court appointed deputy (or equivalent)
    0 … 1
    prsb03-dataelement-13634link
    Record of one or more people who have been given power (LPA) by the person when they had capacity to make decisions about their health and welfare should they lose capacity to make those decisions. To be valid, an LPA must have been registered with the Court of Protection. If life-sustaining treatment is being considered the LPA document must state specifically that the attorney has been given power to consent to or refuse life-sustaining treatment. Details of any person (deputy) appointed by the court to make decisions about the person’s health and welfare. A deputy does not have the power to refuse life-sustaining treatment.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13636link
    The coded value for the LPASNOMED CT: - ^999001951000000107 |Personal welfare lasting power of attorney findings simple reference set (foundation metadata concept)|
    treeblank treeblank treetree draft  Name of LPA
    0 … 1
    prsb03-dataelement-13635link
    The names of any appointed people or deputiesFree text
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-13637link
    The contact details of the LPANHS data dictionary:- UK telephone number
    treetree folder Deprivation of Liberty Safeguards or equivalent
    0 … 1
    prsb03-dataelement-10426link
    Details of the person's Deprivation of Liberty Safeguards (DoLS) or equivalent
    treeblank treetree draft  Application status
    0 … 1
    prsb03-dataelement-13069link
    The status of the DOLs application.Free text : - Requested or authorised
    treeblank treetree draft  Deprivation of liberty safeguards or equivalent
    0 … 1
    prsb03-dataelement-13626link
    Record of Deprivation of Liberty Safeguards (DoLS) or equivalent, including the reason for this.Free text
    treeblank treetree draft  Start date of authorisation
    0 … 1
    prsb03-dataelement-13071link
    The date the DOLs was authorised.Data and time
    treetree folder Mental health act or equivalent status
    0 … *
    prsb03-dataelement-10427link
    Details of the persons mental health act record
    treeblank treetree folder Mental health act or equivalent status
    0 … 1
    prsb03-dataelement-13627link
    Record where a person diagnosed with a mental disorder is formally detained under the Mental health act or equivalent, including the section number. If person subject to Community Treatment Order or Conditional Discharge (or equivalent) record here.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13628link
    The coded value for mental health actNHS data dictionary: - Mental health act legal status classification code
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13629link
    Free text field to be used if no code is availableFree text
    treetree folder Advance decision to refuse treatment (ADRT)
    0 … 1
    prsb03-dataelement-10428link
    Details of the person's ADRT status.
    treeblank treetree folder Advance decision to refuse treatment
    0 … 1
    prsb03-dataelement-13502link
    A record of an advance decision to refuse one or more specific types of future treatment, made by a person who had capacity at the time of recording the decision. The decision only applies when the person no longer has the capacity to consent to or refuse the specific treatment being considered. An ADRT must be in writing, signed and witnessed. If the ADRT is refusing life-sustaining treatment it must state specifically that the treatment is refused even if the person’s life is at risk.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13503link
    The coded value for advance decision to refuse treatment.SNOMED CT:- ^999002181000000105 |Advance decision to refuse treatment preference findings simple reference set (foundation metadata concept)|
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13504link
    Free text field to be used if no code is availableFree text
    folder Safeguarding
    0 … 1
    prsb03-dataelement-271link
    The safeguarding details of the person.
    treetree folder Safeguarding concerns
    0 … *
    prsb03-dataelement-10821link
    Details of safeguarding concerns
    treeblank treetree folder Safeguarding concerns
    0 … 1
    prsb03-dataelement-10171link
    Identified safeguarding concerns.
    treeblank treetree draft  Comment
    0 … 1
    prsb03-dataelement-10175link
    Further details on safeguarding concerns.Free text
    treetree folder Looked after child
    0 … *
    prsb03-dataelement-10797link
    Details of the looked after child
    treetree folder Child protection plan
    0 … *
    prsb03-dataelement-10798link
    Details of the child protection plan
    treetree folder Unborn child protection plan
    0 … *
    prsb03-dataelement-10923link
    Details of the unborn child protection plan.
    folder Professional contacts
    0 … 1
    prsb03-dataelement-452link
    The details of the person’s professional contacts.
    treetree folder Professional contacts record entry
    0 … *
    prsb03-dataelement-10767link
    This is a professional contacts record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
    treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-10352link
    The name of the professional with responsibility for the care of the person.Free text
    treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-10353link
    The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker, key worker, care home manager, care coordinator, LA hospital liaison person, care home contact, hospital clinician, Independent Mental Capacity Advocate (IMCA) etcFHIR value set : - SDSjobrole
    treeblank treetree draft  Speciality
    0 … 1
    prsb03-dataelement-10354link
    The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary : - Activity treatment function code
    treeblank treetree draft  Team
    0 … 1
    prsb03-dataelement-10355link
    The name of the team.Free text
    treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-10356link
    The name of the organisation.
    treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-10357link
    Contact details of the professional (e.g. telephone number, email address etc.).Free text
    treeblank treetree draft  Start date
    0 … 1
    prsb03-dataelement-10358link
    The start date of the professional relationship with the person.Date and time
    treeblank treetree draft  End date
    0 … 1
    prsb03-dataelement-10359link
    The end date of the professional relationship with the person.Date and time
    folder Personal contacts
    0 … 1
    prsb03-dataelement-445link
    The details of the individual's personal contacts.
    treetree folder Personal contacts record entry
    0 … *
    prsb03-dataelement-10768link
    This is personal contacts record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
    treeblank treetree draft  Name
    1 … 1 Mandatory
    prsb03-dataelement-10345link
    The name of the personal contact.Free text
    treeblank treetree draft  Relationship
    0 … 1
    prsb03-dataelement-10346link
    The relationship the personal contact has to the person, e.g. father, grandmother, family friend etc.FHIR value set : - Related person
    treeblank treetree draft  Next of Kin
    0 … 1
    prsb03-dataelement-10349link
    A flag that identifies the personal contact is the next of kinFlag : - Yes or No
    treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-10350link
    Contact details of the personal contact (e.g. telephone number, email address etc.)Free Text
    treeblank treetree draft  Comments
    0 … 1
    prsb03-dataelement-10937link
    Notes on the significance of the personal contact to the person.Free text
    folder Participation in research
    0 … 1
    prsb03-dataelement-168link
    Participation in research
    treetree folder Participation in research record entry
    0 … *
    prsb03-dataelement-10646link
    This is a Participation in research record entry. There may be 0 to many record entry/entries under a section. Each record entry is made up of a number of elements or data items.
    treeblank treetree draft  Name of research study
    0 … 1
    prsb03-dataelement-10068link
    Name and details of the research study/trial and/or drug/interventionFree text or URL
    treeblank treetree draft  Identification code
    0 … 1
    prsb03-dataelement-10739link
    Identification code of research studyNHS data dictionary :- Clinical trial identifier
    folder Referral details
    0 … 1
    prsb03-dataelement-105link
    The details of the referral.
    treetree folder Referral details record entry
    0 … *
    prsb03-dataelement-10917link
    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.
    treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-10006link
    The date of referralDate and time
    treeblank treetree folder Referrer details
    0 … 1
    prsb03-dataelement-10005link
    The details of the referrer that is making the referral or the transfer.

    This could be the person, GP surgery, department, specialty, sub-specialty, educational institution, mental health team, care home etc.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-10971link
    The name of the referrer.Free text
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-10972link
    Role of the referrer.FHIR value set : - sdsjobrole
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-10973link
    The grade of the referrer.Free text
    treeblank treeblank treetree draft  Team
    0 … 1
    prsb03-dataelement-12409link
    The team or department of the referrer.Free text
    treeblank treeblank treetree draft  Specialty
    0 … 1
    prsb03-dataelement-12410link
    The specialty of the referrer.NHS data dictionary - Activity treatment function code
    treeblank treeblank treetree folder Service
    0 … 1
    prsb03-dataelement-12411link
    The service of the referrer.
    treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13397link
    The coded value for serviceSNOMED CT: - 1127531000000102 |Services simple reference set (foundation metadata concept)|
    treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13398link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-10974link
    The organisation of the referrer.
    treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13399link
    The coded value for organisation codeNHS data dictionary : - Organisation data service
    treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13400link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-10975link
    The contact details of the referrer.Free text
    treeblank treetree draft  Referral method
    0 … 1
    prsb03-dataelement-10007link
    The method in which a referral is sent and received. This may be a letter, email, transcript of a telephone conversation, Choose and Book, in person (self-referral) etc.Allow National Codes only Fax Phone Secure Messaging Secure Email Letter NHS E-Referral Service Self referral
    treeblank treetree folder Reason for referral
    0 … 1
    prsb03-dataelement-10011link
    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.Free text
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13455link
    The coded value for reason for referralSNOMED CT :- ^1127581000000103 |Health issues simple reference set|
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13456link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Clinical urgency of referral
    0 … 1
    prsb03-dataelement-10010link
    The details of the clinical urgency of referral
    treeblank treeblank treetree draft  Reason for urgency of referral
    0 … 1
    prsb03-dataelement-10976link
    The reason for urgency of referral if not routine.Free text
    treeblank treetree folder Referral to
    0 … 1
    prsb03-dataelement-10008link
    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.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-10977link
    Name of person the referral is to be sent to.Free text
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-10978link
    Role of person where the referral is to be sent to.FHIR value set : - sdsjobrole
    treeblank treeblank treetree draft  Grade
    0 … 1
    prsb03-dataelement-10979link
    The grade of the person where the referral is sent to.Free text
    treeblank treeblank treetree draft  Team
    0 … 1
    prsb03-dataelement-10982link
    The team or department of the person where the referral is being sent toFree text.
    treeblank treeblank treetree draft  Specialty
    0 … 1
    prsb03-dataelement-10983link
    The specialty the referral is being sent to e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
    treeblank treeblank treetree folder Service
    0 … 1
    prsb03-dataelement-12412link
    The service of where the referral is sent to.
    treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13509link
    The coded value for serviceSNOMED CT: - 1127531000000102 |Services simple reference set (foundation metadata concept)|
    treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13510link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treetree folder Organisation
    0 … 1
    prsb03-dataelement-10980link
    The organisation of where the referral is to be sent.
    treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13511link
    The coded value for organisationNHS data dictionary :- Organisation data service
    treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13512link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treetree draft  Contact details
    0 … 1
    prsb03-dataelement-10981link
    The contact details of where the referral is to be sent.Free text.
    treeblank treetree draft  Referral criteria
    0 … 1
    prsb03-dataelement-10014link
    Records whether specific criteria required for referral, to a particular service, have been met (may be nationally or locally determined). This field is used to outline which criteria have been met where a service has indicated specific criteria and to explain the rationale for referral where criteria have not been met.Free text
    treeblank treetree draft  Return response to
    0 … 1
    prsb03-dataelement-10015link
    Name of professional to be communicated with, if not the referrerFree text.
    folder Contacts with professionals
    0 … 1
    prsb03-dataelement-169link
    The details of the person’s contact with a professional.
    treetree folder Contacts with professionals record entry
    0 … *
    prsb03-dataelement-10718link
    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.
    treeblank treetree draft  Date of contact
    0 … 1
    prsb03-dataelement-10069link
    Date and time of the contact.Date and time.
    treeblank treetree folder Location of contact
    0 … 1
    prsb03-dataelement-10075link
    The location where the contact took place.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13513link
    The coded value for locationNHS data dictionary : - Organisation service code
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13514link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Seen by
    0 … 1
    prsb03-dataelement-10077link
    The professional that saw the person.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-13515link
    The name of the professional that saw the personFree text
    treeblank treeblank treetree cancelled  Free text
    0 … 1
    prsb03-dataelement-13516link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Responsible professional
    0 … 1
    prsb03-dataelement-10072link
    The name and role of the professional that had overall responsibility for the person e.g. consultant, nurse consultant, midwife, allied health professional (may not have actually seen the person).
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-10988link
    The name of the responsible professional.Free text
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-10989link
    The role of the responsible professionalFHIR value set : - sdsjobrole
    treeblank treetree draft  Location type
    0 … 1
    prsb03-dataelement-10076link
    The type of location where the contact took place e.g. person's homeNHS data dictionary - Activity location type code
    treeblank treetree draft  Contact type
    0 … 1
    prsb03-dataelement-10070link
    Type of contact e.g. GP consultation, outpatient attendanceFree text
    treeblank treetree draft  Consultation method
    0 … 1
    prsb03-dataelement-10071link
    Consultation method used e.g. face to face, telephoneNHS data dictionary - Consultation medium
    treeblank treetree draft  Specialty
    0 … 1
    prsb03-dataelement-10073link
    The specialty e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
    treeblank treetree draft  Service
    0 … 1
    prsb03-dataelement-10074link
    The service that was provided.SNOMED CT :- 1127531000000102 |Services simple reference set (foundation metadata concept)|
    treeblank treetree folder Professionals present
    0 … *
    prsb03-dataelement-10078link
    The name, role of the additional individuals or team members including consultant(s), nurse consultant(s), allied health professional(s), social worker(s)
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-10990link
    The name of the professional presentFree text
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-10991link
    The role of the professional present.FHIR value set : - sdsjobrole
    treeblank treetree draft  Outcome of contact
    0 … 1
    prsb03-dataelement-10080link
    This records the outcome of the contact. NHS data dictionary :- Attended or did not attend code
    folder Admission details
    0 … 1
    prsb03-dataelement-181link
    Admission details
    treetree folder Admission details record entry
    0 … *
    prsb03-dataelement-10918link
    This is the admission details record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
    treeblank treetree draft  Date of admission
    0 … 1
    prsb03-dataelement-10085link
    Date and time the person was admitted to hospital.Date and time
    treeblank treetree folder Admitted to
    0 … 1
    prsb03-dataelement-10090link
    The hospital the person was admitted to.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13380link
    The coded value for admission toNHS data dictionary : - Organisations code of provider
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13381link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Responsible care professional
    0 … 1
    prsb03-dataelement-10087link
    The care professional who has overall responsibility for the person (may not actually see the person)
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-10992link
    The name of the responsible care professional.Free text.
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-10993link
    The role of the responsible consultant.FHIR value set: - sdsjobrole
    treeblank treetree folder Reason for admission
    0 … 1
    prsb03-dataelement-10081link
    The health problems and issues experienced by the person that prompted the decision to admit to hospital e.g. chest pain, mental health crisis, blackout, fall, a specific procedure, intervention, investigation or treatment, non compliance with treatment.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13382link
    The coded value for reason for admissionSNOMED CT: - ^1127581000000103 |Health issues simple reference set|
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13384link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Admission method
    0 … 1
    prsb03-dataelement-10082link
    How the person was admitted to hospital e.g. elective, emergency, maternity, transfer etc.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13385link
    The coded value for admission methodNHS data dictionary : - Admission method
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13387link
    Free text field to be used if no code is availableFree text
    treeblank treetree draft  Legal status on admission
    0 … 1
    prsb03-dataelement-10083link
    Whether the person was admitted as informal or formal/detained.NHS data dictionary : - Mental health act legal status classification code
    treeblank treetree folder Source of admission
    0 … 1
    prsb03-dataelement-10084link
    Where the person was immediately prior to admission, e.g. usual place of residence, temporary place of residence, penal establishment.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13388link
    The coded value of source of admissionNHS data dictionary :- Source of admission
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13389link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Individual accompanying person
    0 … 1
    prsb03-dataelement-10088link
    Details of the accompanying individual and the extent to which they have provided the information about the person.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-10984link
    Name of individual accompanying person.Free text
    treeblank treeblank treetree cancelled  Role
    0 … 1
    prsb03-dataelement-10985link
    Role of the individual accompanying the person.NHS data dictionary : - Care professional
    treeblank treeblank treetree folder Relationship
    0 … 1
    prsb03-dataelement-10986link
    Relationship of individual accompanying the person.
    treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13517link
    The coded value for relationship to person.FHIR value set: - Relationship type
    treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13518link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treetree draft  Comment
    0 … 1
    prsb03-dataelement-12447link
    Information about the extent to which the accompanying individual provided information about the person.Free text.
    treeblank treetree folder Specialty
    0 … 1
    prsb03-dataelement-10089link
    The specialty e.g. physiotherapy, oncology, mental health etc
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13390link
    The coded value for specialtyNHS data dictionary :- Activity treatment function code
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13391link
    Free text field to be used if no code is availableFree text
    folder Discharge details
    0 … 1
    prsb03-dataelement-191link
    Discharge details
    treetree folder Discharge details record entry
    0 … *
    prsb03-dataelement-10919link
    This is the discharge details record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
    treeblank treetree draft  Date of discharge
    0 … 1
    prsb03-dataelement-10096link
    The date and time of dischargeDate and time
    treeblank treetree draft  Discharge location
    0 … 1
    prsb03-dataelement-10095link
    The hospital the person was discharged from.NHS data dictionary : - Organisation data service
    treeblank treetree folder Discharging consultant
    0 … 1
    prsb03-dataelement-10093link
    The consultant responsible for the person at time of discharge.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-10994link
    The name of the discharging consultantFree text
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-10995link
    The role of the discharging consultantFHIR value set : - sdsjobrole
    treeblank treetree folder Discharge method
    0 … 1
    prsb03-dataelement-10098link
    The method of discharge from hospital e.g. person discharged on clinical advice or with clinical consent; person discharged him/herself or was discharged by a relative or advocate.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13393link
    The coded value for discharge methodNHS data dictionary : - Discharge method
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13394link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Discharging specialty
    0 … 1
    prsb03-dataelement-10094link
    The specialty of the consultant responsible for the person at the time of discharge.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13395link
    The coded value for discharge specialityNHS data dictionary : - Activity treatment function code
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13396link
    Free text field to be used if no code is availableFree text
    treeblank treetree draft  Discharging department
    0 … 1
    prsb03-dataelement-10987link
    The department from which the person is discharged.Free text
    treeblank treetree draft  Legal status on discharge
    0 … 1
    prsb03-dataelement-10097link
    Whether the person was discharged as informal or formal/detained.NHS data dictionary : - Mental health act classification code
    treeblank treetree folder Discharge destination
    0 … 1
    prsb03-dataelement-10099link
    treeblank treeblank treetree draft  Discharge destination
    0 … 1
    prsb03-dataelement-10100link
    The destination of the person on discharge from hospital e.g. usual place of residence, NHS run care home.NHS data dictionary - Discharge destination.
    treeblank treeblank treetree draft  Discharge address
    0 … 1
    prsb03-dataelement-10101link
    Address to which the person is discharged if not the usual place of residence.NHS data dictionary :- Address
    folder Future appointments
    0 … 1
    prsb03-dataelement-10720link
    Details of future appointments.
    treetree folder Future appointments record entry
    0 … *
    prsb03-dataelement-10721link
    This is the future appointments record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
    treeblank treetree draft  Date of appointment
    0 … 1
    prsb03-dataelement-10722link
    Date and time of future appointment.Date and time
    treeblank treetree draft  Appointment status
    0 … 1
    prsb03-dataelement-10723link
    The status of the appointment e.g. proposed, booked, confirmed, rejected.Free text
    treeblank treetree draft  Reason for appointment
    0 … 1
    prsb03-dataelement-10724link
    Reason this appointment is scheduled e.g. diagnosis, investigation, treatment or assessmentFree text
    treeblank treetree folder Location of future appointment
    0 … 1
    prsb03-dataelement-10726link
    The location of the appointment.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13519link
    The coded value for locationNHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13520link
    Free text field to be used if no code is availableFree text
    treeblank treetree draft  Specialty
    0 … 1
    prsb03-dataelement-10727link
    The specialty e.g. physiotherapy, oncology, mental health etc. NHS data dictionary :- Activity treatment function code
    treeblank treetree draft  Service
    0 … 1
    prsb03-dataelement-10728link
    The service being provided.SNOMED CT: - 1127531000000102 |Services simple reference set (foundation metadata concept)|
    treeblank treetree folder Professional to see the person
    0 … 1
    prsb03-dataelement-10729link
    The name and role of the professional e.g. consultant, care worker, nurse consultant.
    treeblank treeblank treetree draft  Name
    0 … 1
    prsb03-dataelement-12413link
    The name of the professional seeing the person.Free text
    treeblank treeblank treetree draft  Role
    0 … 1
    prsb03-dataelement-12414link
    The role of the professional seeing the person.FHIR value set : - sdsjobrole
    folder Vaccinations
    0 … 1
    prsb03-dataelement-10685link
    Details of vaccinations.
    treetree folder Vaccinations record entry
    0 … *
    prsb03-dataelement-10686link

    This is the vaccinations record entry.

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

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

    treeblank treetree folder Vaccine product
    1 … 1 Mandatory
    prsb03-dataelement-10687link
    The vaccine product administered.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13237link
    The coded value for vaccine product.dm+d (SNOMED) Concept ID AMP (preferred) or VMP term for the vaccine product
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13238link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Manufacturer
    0 … 1
    prsb03-dataelement-10698link
    Name of vaccine manufacturer.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13239link
    The coded value of the manufacturer.SNOMED CT: - DM+D or GS1
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13240link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Vaccine procedure
    1 … 1 Mandatory
    prsb03-dataelement-10688link
    The procedure which was used to administer the vaccine.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13219link
    The coded value for vaccine procedureSNOMED CT :- < 127785005 |Administration of substance to produce immunity, either active or passive (procedure)| or  << 1066171000000108 Seasonal influenza vaccination given by midwife or << 713404003 Vaccination given (code and all its descendants)
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13220link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Body site
    0 … 1
    prsb03-dataelement-10691link
    Body site vaccine was administered.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13222link
    The coded value for body siteSNOMED CT : - ^1127941000000100 |Vaccine body site of administration simple reference set (foundation metadata concept)|
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13223link
    Free text field to be used if no coded text available
    treeblank treetree folder Route
    0 … 1
    prsb03-dataelement-10692link
    How the vaccine entered the body.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13224link
    The coded value for vaccination routeSNOMED CT: - ^999000051000001100 |ePrescribing route of administration simple reference set (foundation metadata concept)|
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13225link
    Free text field to be used if no coded text available
    treeblank treetree folder Indication
    0 … 1
    prsb03-dataelement-10693link
    The clinical indication or reason for administering the vaccine.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13226link
    The coded value for Indication.SNOMED CT:- ^1127601000000107 | Healthcare matters simple reference set (foundation metadata concept) |
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13227link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Dose amount
    0 … 1
    prsb03-dataelement-10694link
    Amount of vaccine administered.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13228link
    Amount of vaccine administered.SNOMED CT : - dm+d
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13229link
    Amount of vaccine administered.Free text
    treeblank treetree draft  Dose sequence
    0 … 1
    prsb03-dataelement-10824link
    Nominal position in a series of vaccines.Numeric value
    treeblank treetree folder Outcome status
    0 … 1
    prsb03-dataelement-10838link
    Whether the vaccine was administered or not, including the reason why
    treeblank treeblank treetree draft  Not given flag
    0 … 1
    prsb03-dataelement-13230link
    Flag to indicate that the vaccination was NOT given at this time by a healthcare professionalFlag: - Yes or No
    treeblank treeblank treetree draft  Vaccination situation (not given reason)
    0 … 1
    prsb03-dataelement-13231link
    The reason why a vaccination was not administered.FHIR value set : - Reason code
    treeblank treetree folder Reported
    0 … 1
    prsb03-dataelement-10825link
    Details of the vaccination reported to the professional
    treeblank treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-10837link
    The date or partial date that the reported vaccination was given in the opinion of the person.Date/time
    treeblank treeblank treetree draft  Report origin
    0 … 1
    prsb03-dataelement-13232link
    The source of the data when the report of the vaccination event is not based on information from the person who administered the vaccine.FHIR value set:- https://www.hl7.org/fhir/valueset-immunization-origin.html
    folder Problem list
    0 … 1
    prsb03-dataelement-10927link
    A summary of the problems that require investigation or treatment.
    treetree folder Problem list record entry
    0 … *
    prsb03-dataelement-10928link
    This is a problem list record entry.

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

    Each record entry is made up of a number of elements or data items.
    treeblank treetree folder Problem
    1 … 1 Mandatory
    prsb03-dataelement-10932link
    A condition which needs addressing and so is important for every professional to know about when seeing the person.

    Problems may include diagnoses, symptoms, disabilities and social or behavioural issues
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13244link
    The coded value for the problem list.SNOMED CT : - ^1127581000000103 |Health issues simple reference set|
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13245link
    Free text field to be used if no code is availableFree text
    treeblank treetree draft  Onset date
    0 … 1
    prsb03-dataelement-10933link
    A date or estimated date that the problem beganDate and time
    treeblank treetree draft  End Date
    0 … 1
    prsb03-dataelement-10934link
    The date or estimated date the problem was resolved.Date and time.
    treeblank treetree draft  Stage of disease
    0 … 1
    prsb03-dataelement-10935link
    The stage of the disease where relevant.Free text
    treeblank treetree draft  Comment
    0 … *
    prsb03-dataelement-10936link
    Supporting text may be given covering the problem.Free text
    folder Procedures and therapies
    0 … 1
    prsb03-dataelement-238link
    The details of any procedures performed. Includes both psychological and medical therapies and procedures (e.g. cognitive behaviour therapy, hip replacement)
    treetree folder Procedure record entry
    0 … *
    prsb03-dataelement-10652link
    This is a procedure record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
    treeblank treetree folder Procedure
    1 … 1 Mandatory
    prsb03-dataelement-10141link
    The therapeutic or diagnostic procedure performed. Includes both psychological and medical therapies and procedures (e.g. cognitive behaviour therapy, or follow-up interventions as a result of physical health checks). Complementary or alternative procedures and therapies should be recorded here.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13249link
    The procedure code.SNOMED CT : - <<71388002 |Procedure| OR <<129125009 |Procedure with explicit context|
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13250link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Anatomical site
    0 … 1
    prsb03-dataelement-10142link
    The body site of the procedure
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13251link
    The coded value of the anatomical site.SNOMED CT :- <123037004 |Body structure (body structure)|
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13252link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Laterality
    0 … 1
    prsb03-dataelement-10143link
    Laterality of the procedure
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13253link
    The coded value for laterality.SNOMED CT:- <182353008 |Side (qualifier value)|
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13254link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Complications related to procedure
    0 … 1
    prsb03-dataelement-10144link
    Details of any intra-operative complications encountered during the procedure, arising during the person’s stay in the recovery unit or directly attributable to the procedure.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13255link
    The coded value for complications relating to procedure.SNOMED CT : - <404684003 |Clinical finding (finding)|
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13256link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Specific anesthesia issues
    0 … 1
    prsb03-dataelement-10145link
    Details of any adverse reaction to any anesthetic agents including local anesthesia. Problematic intubation, transfusion reaction, etc.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13257link
    The coded value for specific anesthesia issues.SNOMED CT
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13258link
    Free text field to be used if no code is availableFree text
    treeblank treetree draft  Comment
    0 … 1
    prsb03-dataelement-10146link
    Any further textual comment to clarify such as statement that information is partial or incomplete. Also indicate the outcome of the procedure.Free text
    folder Social context
    0 … 1
    prsb03-dataelement-136link
    The social setting in which the person lives, such as their household, occupational history, and lifestyle factors.
    treetree folder Household composition
    0 … 1
    prsb03-dataelement-10036link
    Details of the person's household composition.
    treeblank treetree folder Household composition
    0 … 1
    prsb03-dataelement-13261link
    Description of the household composition e.g. lives alone, lives with family, lives with partner, etc.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13262link
    The coded value of household compositionSNOMED CT: - 1027891000000106 | Household composition findings simple reference set (foundation metadata concept) |
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13263link
    Free text field to be used if no code is availableFree text
    treetree folder Occupational history
    0 … 1
    prsb03-dataelement-10037link
    The current and/or previous occupation(s) of the person.
    treeblank treetree folder Occupational history
    0 … 1
    prsb03-dataelement-13264link
    The current and/or previous occupation(s) of the person.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13265link
    The coded value for occupational historySNOMED CT : - ^999001571000000109 | Occupation simple reference set (foundation metadata concept)
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13266link
    Free text field to be used if no code is availableFree text
    treetree folder Educational history
    0 … 1
    prsb03-dataelement-10038link
    Details of the person's educational history.
    treeblank treetree folder Educational history
    0 … 1
    prsb03-dataelement-13267link
    The current and/or previous relevant educational history of the person.Free text
    treetree folder Lifestyle choices
    0 … 1
    prsb03-dataelement-10039link
    The lifestyle choices made by the person which are pertinent to his or her health and well-being, e.g. physical activity level, pets, hobbies and sexual habits
    treeblank treetree folder Lifestyle choices
    0 … 1
    prsb03-dataelement-13268link
    The lifestyle choices made by the person which are pertinent to his or her health and well-being, e.g. physical activity level, pets, hobbies and sexual preferences.Free text
    treeblank treeblank treetree cancelled  Coded value
    0 … 1
    prsb03-dataelement-13269link
    The coded value of the person's lifestyle choice.SNOMED CT
    treeblank treeblank treetree cancelled  Free text
    0 … 1
    prsb03-dataelement-13270link
    Free text field to be used if no code is availableFree text
    treetree folder Smoking status
    0 … 1
    prsb03-dataelement-10040link
    Details of the person's smoking status.
    treeblank treetree folder Smoking status
    0 … 1
    prsb03-dataelement-13283link
    Record of any smoking use by the person.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13284link
    The smoking status of the person.SNOMED CT:- ^999000891000000102 |Smoking simple reference set (foundation metadata concept)|
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13285link
    Free text field to be used if no code is availableFree text
    treeblank treetree draft  Smoking status - details
    0 … 1
    prsb03-dataelement-13286link
    Further details recorded about the smoking status of the personFree text
    treeblank treetree folder Date stopped smoking
    0 … 1
    prsb03-dataelement-13287link
    The date the person stopped smoking (if known)
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13288link
    The coded value for date stopped smoking.SNOMED CT:- 160625004 |Date ceased smoking (observable entity)|
    treeblank treeblank treetree draft  Date
    0 … 1
    prsb03-dataelement-13289link
    The date the person stopped smoking.Date and time
    treetree folder Alcohol intake
    0 … 1
    prsb03-dataelement-10041link
    Details of the person's alcohol intake
    treeblank treetree folder Alcohol intake
    0 … 1
    prsb03-dataelement-13290link
    Latest or current alcohol consumption.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13291link
    The coded value of the person alcohol intakeSNOMED CT :- 219006 |Current drinker of alcohol (finding)| OR 105542008 |Current non-drinker of alcohol (finding)| OR 228274009 |Lifetime non-drinker (finding)| OR 1104551000000109 |Declined to provide information about alcohol use (situation)| OR 371434005 |History of alcohol abuse (situation)|
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13292link
    Free text field to be used if no code is availableFree text
    treetree folder Drug/substance use
    0 … 1
    prsb03-dataelement-10042link
    Details of the person's drug and substance use.
    treeblank treetree folder Drug/substance use
    0 … 1
    prsb03-dataelement-13336link
    Latest or current drug/substance use.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13337link
    The coded value for drug and substance misuse.SNOMED CT:- 361055000 |Misuses drugs (finding)| OR 371422002 |History of substance abuse (situation)| OR 228368007 |Has never misused drugs (situation)| OR 783241000000102 |Declined to give substance misuse history (finding)|
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13338link
    Free text field to be used if no code is availableFree text
    treetree folder Social circumstances
    0 … 1
    prsb03-dataelement-10043link
    Details of the persons social circumstances
    treeblank treetree draft  Social circumstances
    0 … 1
    prsb03-dataelement-13341link
    A person’s social background, network and personal circumstances, e.g. housing. This should include whether the person is a carer.Free text
    treetree folder Access
    0 … 1
    prsb03-dataelement-10045link
    Details of access for the person.
    treeblank treetree draft  Access
    0 … 1
    prsb03-dataelement-13342link
    Special access requirements e.g. key safe, coded lock, which door to use, stretcher access, etc.Free text
    treetree folder Dependants
    0 … 1
    prsb03-dataelement-10046link
    Details of any responsibility the person has for dependants.
    treeblank treetree draft  Dependants
    0 … 1
    prsb03-dataelement-13345link
    Provide details of any responsibility the person has for dependants. In the case of children provide date of birth of the child.Free text
    treetree folder Accommodation status
    0 … 1
    prsb03-dataelement-10047link
    Details of the type of accommodation where the person lives.
    treeblank treetree folder Accommodation status
    0 … 1
    prsb03-dataelement-13348link
    An indication of the type of accommodation where the person lives.

    This should be based on the main or permanent residence.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13349link
    The coded value for accommodation statusNHS data dictionary :- Accommodation status
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13350link
    Free text field to be used if no code is availableFree text
    treetree folder Household environment
    0 … 1
    prsb03-dataelement-10051link
    Details of the person's household environment.
    treeblank treetree folder Household environment
    0 … 1
    prsb03-dataelement-13355link
    Factors in the household which impact the person's health and wellbeing, to include smoking in the home, alcohol/substance use etc.Free text
    folder Services and care
    0 … 1
    prsb03-dataelement-10044link
    The services and care provided for the person.
    treetree folder Services and care record entry
    0 … *
    prsb03-dataelement-12421link
    This is a services and care record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
    treeblank treetree draft  Social care package name
    0 … 1
    prsb03-dataelement-12965link
    Name of specific type of package being provided (e.g. Reablement, Home Based Care XYZ, etc)Free text
    treeblank treetree draft  Social care package type
    0 … 1
    prsb03-dataelement-12966link
    Higher level categorisation of package type, e.g. Adults Home SupportFree text
    treeblank treetree folder Local authority
    0 … 1
    prsb03-dataelement-11835link
    The name of the local authority providing the care package.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13566link
    The coded value for local authorityNHS data dictionary: - Organisation data service
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13567link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Care funding source
    0 … 1
    prsb03-dataelement-13067link
    A reference to the funding source and any conditions or limitations associated.
    folder Family history
    0 … 1
    prsb03-dataelement-251link
    Family history
    treetree folder Family history record entry
    0 … *
    prsb03-dataelement-10653link
    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.
    treeblank treetree folder Relationship to person
    0 … 1
    prsb03-dataelement-10155link
    The relationship of the family member with the condition to the person.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13676link
    The coded value for relationship to personSNOMED CT: - <303071001 |Person in the family (person)|
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13677link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Family history
    0 … 1
    prsb03-dataelement-10151link
    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.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13678link
    The coded value for family historySNOMED CT:- <404684003 |Clinical finding (finding)| OR <243796009 |Situation with explicit context (situation)|
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13679link
    Free text field to be used if no coded text available
    treeblank treetree folder Condition or diagnosis
    0 … 1
    prsb03-dataelement-10152link
    The condition or diagnosis of the family member deemed to be significant to the care or health of the person.
    treeblank treeblank treetree cancelled  Coded value
    0 … 1
    prsb03-dataelement-13680link
    The coded value for condition or diagnosisSNOMED CT: - 999000771000000106 | Family history simple reference set (foundation metadata concept) |
    treeblank treeblank treetree cancelled  Free text
    0 … 1
    prsb03-dataelement-13681link
    Free text field to be used if no code is availableFree text
    treeblank treetree draft  Comment
    0 … 1
    prsb03-dataelement-10156link
    Any further textual comment.Free text
    folder Investigation results
    0 … 1
    prsb03-dataelement-257link
    Investigation results
    treetree folder Investigation results record entry
    0 … *
    prsb03-dataelement-10654link
    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.
    treeblank treetree folder Investigation
    1 … 1 Mandatory
    prsb03-dataelement-10160link
    The investigation performed.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13525link
    The coded value for investigationSNOMED CT: - <71388002 |Procedure (procedure)|
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13526link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Investigation result
    0 … 1
    prsb03-dataelement-10161link
    For each investigation, the result of the investigation. This can include a report which may have results for multiple tests.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13527link
    The coded value for investigation resultsSNOMED CT:- <404684003 |Clinical finding (finding)| OR <243796009 |Situation with explicit context (situation)|
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13528link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Structured investigation result
    0 … 1
    prsb03-dataelement-12415link
    A structured set of information for each investigation result.
    treeblank treeblank treetree draft  Value
    0 … 1
    prsb03-dataelement-12416link
    The value of the investigation result.Numeric
    treeblank treeblank treetree draft  Units of measure
    0 … 1
    prsb03-dataelement-12417link
    The units of the investigation result.UCUM code
    treeblank treeblank treetree draft  Reference ranges
    0 … 1
    prsb03-dataelement-12418link
    The reference range for the investigation result.Free text
    treeblank treeblank treetree draft  Abnormal indicator
    0 … 1
    prsb03-dataelement-12419link
    Indicator if the investigation is abnormal.Abnormal or Normal
    folder Investigations requested
    0 … 1
    prsb03-dataelement-10730link
    Details of any investigations requested
    treetree folder Investigations requested record entry
    0 … *
    prsb03-dataelement-10731link
    This is an investigation requested record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
    treeblank treetree folder Investigation requested
    1 … 1
    prsb03-dataelement-10733link
    The investigation that is requested. The investigation may refer to an individual test or a group of related tests or broader investigation required (so the investigator can determine the appropriate tests)
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13529link
    The coded value for Investigation requestedSNOMED CT: - <71388002 |Procedure (procedure)|
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13530link
    Free text field to be used if no code is availableFree text
    treeblank treetree draft  Status of request
    0 … 1
    prsb03-dataelement-10734link
    The status of the investigation request.Code : - draft | active | suspended | completed | entered-in-error | cancelled
    treeblank treetree draft  Reason for request
    0 … 1
    prsb03-dataelement-10737link
    An explanation or justification for why this investigation is being requested.Free text
    treeblank treetree draft  Request priority
    0 … 1
    prsb03-dataelement-10738link
    The urgency of the investigation requested.Code : - routine | urgent | asap | stat
    folder Examination findings
    0 … 1
    prsb03-dataelement-557link
    Examination findings
    treetree folder Examination findings record entry
    0 … *
    prsb03-dataelement-10662link
    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.
    treeblank treetree folder Examination findings
    0 … 1
    prsb03-dataelement-10458link
    The record of findings from the examinations performed.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13443link
    The coded value for examination findingsSNOMED CT : - ^1127601000000107 |Healthcare matters simple reference set (foundation metadata concept)|
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13444link
    Free text field to be used if no coded text available
    treeblank treetree folder Observations
    0 … 1
    prsb03-dataelement-10464link
    The record of essential physiological measurements, e.g., heart rate, blood pressure, temperature, pulse, height, weight, respiratory rate, oxygen saturation.
    treeblank treeblank treetree folder Observations record entry
    0 … *
    prsb03-dataelement-13866link
    This is an observations record entry. There may be 0 to many record entry/entries under a section. Each record entry is made up of a number of elements or data items.
    treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13447link
    The coded value for observationsSNOMED CT: - <363787002 | Observable entity (observable entity) |
    treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13448link
    Free text field to be used if no code is availableFree text
    treeblank treetree draft  Comments
    0 … 1
    prsb03-dataelement-10476link
    Any further comments relating to the examination.Free text
    folder Pregnancy status
    0 … 1
    prsb03-dataelement-10814link
    Pregnancy status of the person.
    treetree draft  Pregnancy state
    0 … 1
    prsb03-dataelement-10815link
    A flag that indicates whether the person is pregnant.Flag : - Yes or No
    treetree draft  Expected delivery date
    0 … 1
    prsb03-dataelement-10813link
    The expected delivery date of the person.Date and time
    folder Assessments
    0 … 1
    prsb03-dataelement-262link
    Details of the person's assessments
    treetree folder Assessments record entry
    0 … *
    prsb03-dataelement-11664link
    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.
    treeblank treetree draft  Assessment type
    0 … 1
    prsb03-dataelement-10822link
    The type of the assessment e.g. social care needs assessment.Free text
    treeblank treetree draft  Assessment summary
    0 … 1
    prsb03-dataelement-10754link
    The summary of the assessmentFree text
    treeblank treetree folder Structured assessment
    0 … 1
    prsb03-dataelement-10655link
    Details of the structured assessment.
    treeblank treeblank treetree draft  Structured assessment name
    0 … 1
    prsb03-dataelement-11751link
    Structured assessment name e.g. New York Heart Failure, Glasgow Coma scale, Activities of Daily Living (ADL) etc.SNOMED CT
    treeblank treeblank treetree draft  Assessment score
    0 … 1
    prsb03-dataelement-10162link
    The structured assessment score.Free text.
    treeblank treeblank treetree draft  Assessment value
    0 … 1
    prsb03-dataelement-10163link
    The structured assessment value.Numeric
    treeblank treeblank treetree draft  Subscale score
    0 … *
    prsb03-dataelement-10169link
    The subscale score of the structured assessment.Free text.
    treeblank treeblank treetree draft  Subscale value
    0 … *
    prsb03-dataelement-10170link
    The subscale value of the structured assessment.Numeric
    treeblank treetree draft  Comment
    0 … 1
    prsb03-dataelement-10164link
    Supporting text may be given regarding the assessment.Free text
    folder Formulation
    0 … 1
    prsb03-dataelement-11666link
    Details of the person's formulation.
    treetree folder Formulation record entry
    0 … *
    prsb03-dataelement-11667link
    This is the formulation record entry. There may be 0 to many record entry/entries under a section. Each record entry is made up of a number of elements or data items.
    treeblank treetree draft  Formulation
    1 … 1 Mandatory
    prsb03-dataelement-11668link
    An account, shared by a therapist and person, of the personal meaning and origins of a person’s difficulties. This is viewed in the context of multiple factors including relationships, social circumstances and life events and will indicate the most helpful way forward.Free text
    folder Risks
    0 … 1
    prsb03-dataelement-276link
    Details of any risks related to the person.
    treetree folder Risks to self
    0 … *
    prsb03-dataelement-10176link
    Details of the persons risk to self
    treeblank treetree draft  Risk to self
    0 … 1
    prsb03-dataelement-13579link
    Risks the person poses to themselves, e.g. suicide, overdose, self-harm, self-neglect.SNOMED CT: - <281694009 |Finding of at risk (finding)|
    treetree folder Risks to others
    0 … *
    prsb03-dataelement-10177link
    Details of the person's risk to others
    treeblank treetree draft  Risks to others
    0 … 1
    prsb03-dataelement-13580link
    Risks to professionals or others.SNOMED CT: - <<391155006 |At risk of harming others (finding)|
    treetree folder Risk from others
    0 … *
    prsb03-dataelement-10178link
    Risks to the person from an identified individual e.g. family member etc.Free Text.
    treeblank treetree draft  Risk from others
    0 … 1
    prsb03-dataelement-13581link
    Risks to the person from an identified individual e.g. family member etc.SNOMED CT: - <281694009 |Finding of at risk (finding)|
    treetree folder Risk of accidents
    0 … *
    prsb03-dataelement-10751link
    Details of the risks the person poses to themselves from accidents.
    treeblank treetree draft  Risk of accidents
    0 … 1
    prsb03-dataelement-13582link
    Risks the person poses to themselves from accidents.Free text
    treetree folder Other risks
    0 … *
    prsb03-dataelement-10802link
    Details of other risks, factors or behaviours relating to the person.
    treeblank treetree draft  Other risks
    0 … 1
    prsb03-dataelement-13583link
    Other risks, factors or behaviours relating to the person.Free text
    folder Allergies and adverse reactions
    0 … 1
    prsb03-dataelement-282link
    Allergies and adverse reactions
    treetree folder Allergies and adverse reactions record entry
    0 … *
    prsb03-dataelement-10657link
    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.
    treeblank treetree draft  Type of reaction
    0 … 1
    prsb03-dataelement-10186link
    The type of reaction experienced by the person (allergic, adverse, intolerance)FHIR value set :- Allergy, Intolerance
    treeblank treetree folder Causative agent
    1 … 1
    prsb03-dataelement-10182link
    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”
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13441link
    The coded value for causative agent 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)
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13442link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Reaction details cluster
    0 … 1
    prsb03-dataelement-10658link
    Details of the reaction.
    treeblank treeblank treetree folder Substance
    0 … 1
    prsb03-dataelement-11665link
    The substance, or a class of substances, that is considered to be responsible for the adverse reaction.
    treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13554link
    The coded value for substanceSNOMED CT : - <105590001 | Substance (substance) | or <373873005 | Pharmaceutical / biologic product (product) |
    treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13555link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treetree folder Description of reaction
    0 … 1
    prsb03-dataelement-10183link
    A description of the manifestation of the allergic or adverse reaction experienced by the person. For example, skin rash.
    treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13556link
    The coded value for description of reaction.SNOMED CT: - ^1127581000000103 |Health issues simple reference set|
    treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13557link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treetree folder Severity
    0 … 1
    prsb03-dataelement-10184link
    A description of the severity of the reaction.
    treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13558link
    The coded value for severityFHIR value set : - Severity
    treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13559link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treetree folder Certainty
    0 … 1
    prsb03-dataelement-10185link
    A description of the certainty that the stated causative agent caused the allergic or adverse reaction.
    treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13560link
    The coded value for certainty.FHIR value set : - Certainty
    treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13561link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treetree draft  Comment
    0 … 1
    prsb03-dataelement-10189link
    Any additional comment or clarification about the adverse reaction.Free text
    treeblank treetree draft  Evidence
    0 … 1
    prsb03-dataelement-10187link
    Results of investigations that confirmed the certainty of the diagnosis. Examples might include results of skin prick allergy testsFree text
    treeblank treetree draft  Date first experienced
    0 … 1
    prsb03-dataelement-10188link
    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)Date and time
    folder Medications and medical devices
    0 … 1
    prsb03-dataelement-636link
    Medications and medical devices
    treetree folder Medication item entry
    0 … *
    prsb03-dataelement-10663link
    All medications and devices that can be prescribed to be entered via this Medication item entry. Handles details of continuation / addition / amendment of admission medications.
    treeblank treetree folder Medication item cluster
    0 … 1
    prsb03-dataelement-10664link
    Medication item cluster
    treeblank treeblank treetree folder Medication name
    0 … 1
    prsb03-dataelement-10536link
    May be generic name or brand name.
    treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13622link
    The coded value for medication namedm+d:- any code from the VTM, VMP, AMP, VMPP and AMPP concept classes
    treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13623link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treetree folder Form
    0 … 1
    prsb03-dataelement-10537link
    The form of the medication e.g. capsule, drops, tablet, lotion etc.
    treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13624link
    The coded value for form.SNOMED CT: - ^999000781000001107 | National Health Service dictionary of medicines and devices dose form simple reference set (foundation metadata concept) |
    treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13625link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treetree folder Route
    0 … 1
    prsb03-dataelement-10538link
    The route by which the medication is administered e.g. oral, IM, IV
    treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13655link
    The coded value for routeSNOMED CT: - ^999000051000001100 |ePrescribing route of administration simple reference set (foundation metadata concept)|
    treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13656link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treetree folder Site
    0 … 1
    prsb03-dataelement-10540link
    The anatomical site at which the medication is to be administered.
    treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13657link
    The coded value for siteSNOMED CT: - <442083009 | Anatomical or acquired body structure (body structure) |
    treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13658link
    Free text field to be used when code is not availableFree text
    treeblank treeblank treetree folder Method
    0 … 1
    prsb03-dataelement-10541link
    The technique or method by which the medication is to be administered.
    treeblank treeblank treetree draft  Over the counter medication flag
    0 … 1
    prsb03-dataelement-13379link
    Indicates if the medication or device is acquired without a prescription i.e. got by the person over the counterFlag : - Yes or No
    treeblank treeblank treetree folder Structured dose direction cluster
    0 … 1
    prsb03-dataelement-11639link
    A structural representation of the elements carried by the dose syntax in 'parsable dose strength / timing' i.e. dose strength, dose timing, dose duration and maximum dose.
    treeblank treeblank treeblank treetree folder Structured dose amount
    0 … 1
    prsb03-dataelement-10554link
    A structural representation of dose amount, e.g. 20mg or 2 tablets. This element will generally only be used when persisting data within systems with 'parsable dose directions' being used to exchange the same information between systems. As per FHIR Dose Syntax Implementation Guidance (NHS Digital): https://simplifier.net/guide/DoseSyntaxImplementationGuidanceforFHIRR4/Home
    treeblank treeblank treeblank treetree draft  Structured dose timing
    0 … 1
    prsb03-dataelement-10555link
    A slot containing a structural, computable representation of dose timing and maximum dose. This element will generally only be used when persisting data within systems with 'parsable dose directions' being used to exchange the same information between systems. As per FHIR Dose Syntax Implementation Guidance (NHS Digital): https://simplifier.net/guide/DoseSyntaxImplementationGuidanceforFHIRR4/Home Numeric
    treeblank treeblank treeblank treetree draft  Dose direction duration
    0 … 1
    prsb03-dataelement-10548link
    Recommendation of the time period for which the medication should be continued, including direction not to discontinue. As per FHIR Dose Syntax Implementation Guidance (NHS Digital): https://simplifier.net/guide/DoseSyntaxImplementationGuidanceforFHIRR4/Home Numeric
    treeblank treeblank treeblank treetree draft  Dose directions description
    0 … 1
    prsb03-dataelement-10544link
    Describes the entire medication dosage and administration directions including dose quantity and medication frequency and optionally duration e.g. “1 tablet at night" or “2mg at 10pm”.Free text
    treeblank treeblank treetree draft  Additional instructions
    0 … 1
    prsb03-dataelement-10545link
    Allows for: requirements for adherence support, e.g. compliance aids, prompts and packaging requirements, additional information about specific medicines e.g. where specific brand required, person requirements, e.g. unable to swallow tablets.FHIR value set : - Additional instruction
    treeblank treeblank treetree folder Course details cluster
    0 … 1
    prsb03-dataelement-10561link
    Details of the overall course of medication.
    treeblank treeblank treeblank treetree draft  Course status
    0 … 1
    prsb03-dataelement-10666link
    The status of this prescription.FHIR value set : - Medication status
    treeblank treeblank treeblank treetree draft  Indication
    0 … 1
    prsb03-dataelement-10546link
    Reason for medication being prescribed, where known.Free text
    treeblank treeblank treeblank treetree draft  Start date/time
    0 … 1
    prsb03-dataelement-10667link
    The date and/or time that the medication course should begin.Date and time
    treeblank treeblank treeblank treetree draft  End date/time
    0 … 1
    prsb03-dataelement-10557link
    The date and/or time that the medication course should finish.Date and time
    treeblank treeblank treeblank treetree draft  Link to indication record
    0 … 1
    prsb03-dataelement-10668link
    A link to the record which contains the indication for this medication order.Free text with URL
    treeblank treeblank treeblank treetree draft  Comment/recommendation
    0 … 1
    prsb03-dataelement-10547link
    Suggestions about duration and/or review, ongoing monitoring requirements, advice on starting, discontinuing or changing medication. Additional comment or recommendation about the medication course e.g. 'Patient named supply', 'unlicensed medication', 'Foreign brand' or monitoring recommendationsFree text
    treeblank treeblank treetree folder Medication change summary cluster
    0 … 1
    prsb03-dataelement-10568link
    Records the changes made to medication.
    treeblank treeblank treeblank treetree draft  Status
    0 … 1
    prsb03-dataelement-10669link
    The nature of any change made to the medication.FHIR value set : Medication status
    treeblank treeblank treeblank treetree draft  Indication
    0 … 1
    prsb03-dataelement-10670link
    Reason for change in medication, e.g. sub-therapeutic dose, person intolerant. SNOMED CT:- ^1127601000000107 | Healthcare matters simple reference set (foundation metadata concept) |
    treeblank treeblank treeblank treetree draft  Date of change
    0 … 1
    prsb03-dataelement-10671link
    The date of the change - addition, or amendmentDate and time
    treeblank treeblank treeblank treetree draft  Description of amendment
    0 … 1
    prsb03-dataelement-10672link
    Where a change is made to the medication i.e. one drug stopped and another started or eg dose, frequency or route is changed.Free text
    treeblank treeblank treetree draft  Total dose daily quantity
    0 … 1
    prsb03-dataelement-10665link
    The total daily dose of this medication. This is helpful for estimating optimal adherence to dosing guidance. It may be computed from product/dose strength and frequency or entered manually.Free text
    treeblank treetree folder Medical devices entry
    0 … *
    prsb03-dataelement-10583link
    Medical devices
    treeblank treeblank treetree draft  Medical device
    0 … 1
    prsb03-dataelement-10673link
    Any medical device that isn't prescribed.Free text
    treeblank treeblank treetree draft  Comments
    0 … 1
    prsb03-dataelement-11280link
    Any information regarding the medical device.Free text
    treeblank treetree folder Medication discontinued entry
    0 … *
    prsb03-dataelement-10576link
    Medication discontinued entry
    treeblank treeblank treetree folder Name of discontinued medication
    0 … 1
    prsb03-dataelement-10577link
    The name of the medication or medical device being discontinued
    treeblank treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13659link
    The coded value for medication name dm+d:- any code from the VTM, VMP, AMP, VMPP and AMPP concept classes
    treeblank treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13660link
    Amount of vaccine administered.Free text
    treeblank treeblank treetree draft  Status
    0 … 1
    prsb03-dataelement-12472link
    The status of any change made to the medication. MUST CONTAIN STOPPED.FHIR value set: - Medication status
    treeblank treeblank treetree draft  Indication
    0 … 1
    prsb03-dataelement-10579link
    The clinical indication for any changes in medication status SNOMED CT:- ^1127601000000107 | Healthcare matters simple reference set (foundation metadata concept) |
    treeblank treeblank treetree draft  Date of change
    0 … 1
    prsb03-dataelement-10580link
    The date of the discontinuationDate and time
    treeblank treeblank treetree draft  Comment
    0 … 1
    prsb03-dataelement-10582link
    Any additional comment about the discontinuation or amendment.Free text
    folder Plan and requested actions
    0 … 1
    prsb03-dataelement-535link
    The details of planned investigations, procedures and treatment, and whether this plan has been agreed with the person or their legitimate representative.
    treetree folder Plan and requested actions record entry
    0 … *
    prsb03-dataelement-10661link
    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.
    treeblank treetree draft  Actions for professionals
    0 … 1
    prsb03-dataelement-10436link
    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.Free text
    treeblank treetree draft  Actions for person or their carer
    0 … 1
    prsb03-dataelement-10437link
    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.Free text
    treeblank treetree draft  Agreed with the person or their legitimate representative
    0 … 1
    prsb03-dataelement-10438link
    Indicates whether the person or their legitimate representative has agreed the entire plan or individual aspects of treatment, expected outcomes, risks and alternative treatments. A record of the agreement of the decisions made.Free text
    treeblank treetree draft  Outcome of plan and requested actions
    0 … *
    prsb03-dataelement-10950link
    The details of the outcome of the plan and requested actions.Free text.
    folder Care and support plan
    0 … 1
    prsb03-dataelement-508link
    This records the decisions reached during conversation between the individual and health and care professional about future plans and also records progress.
    treetree folder Strengths
    0 … *
    prsb03-dataelement-10419link
    Any strengths and assets the person has relating to their goals and hopes about their health and well-being.
    treetree folder Needs, concerns or problems
    0 … *
    prsb03-dataelement-10414link
    Details of the person needs, concerns or problems
    treeblank treetree folder Goals and hopes
    0 … *
    prsb03-dataelement-10413link
    The overall goals, hopes, aims or targets that the person has. Including anything that the person wants to achieve that relates to their future health and wellbeing. Each goal may include a description of why it is important to the person. Goals may also be ranked in order of importance or priority to the person.
    treeblank treeblank treetree folder Actions and activities
    0 … *
    prsb03-dataelement-10408link
    Actions or activities the person or others plan to take to achieve the person's goals and the resources required to do this.

    treeblank treeblank treeblank treetree folder What
    0 … 1
    prsb03-dataelement-10675link
    What the action is and how it is to be carried out?
    treeblank treeblank treeblank treetree folder Who
    0 … 1
    prsb03-dataelement-10676link
    Name and role (e.g. person, carer, GP, OT, etc.) of the person, or a team, carrying out the proposed action, and, if relevant where action should take place.
    treeblank treeblank treeblank treetree draft  When
    0 … 1
    prsb03-dataelement-10677link
    Planned date, time, or interval, as relevantDate and time
    treeblank treeblank treeblank treetree draft  Suggested strategies
    0 … 1
    prsb03-dataelement-10678link
    Suggested strategies for potential problems.Free text.
    treeblank treeblank treeblank treetree folder Status
    0 … 1
    prsb03-dataelement-10679link
    The status of the action or activity e.g. in progress, done, refused
    treeblank treeblank treeblank treetree draft  Confidence
    0 … 1
    prsb03-dataelement-10680link
    How confident the person feels to carry out the action associated to the goal.Numeric score 1 - 10
    treeblank treeblank treeblank treetree draft  Date last updated
    0 … 1
    prsb03-dataelement-10682link
    Date when action/activity record was last updatedDate and time
    treeblank treeblank treeblank treetree draft  Review date
    0 … 1
    prsb03-dataelement-10683link
    When the action evaluation needs to be reviewed. SNOMED CT tag : - 425268008 | Review of care plan (procedure) |Date and time.
    treeblank treeblank treeblank treetree folder Stage goal
    0 … 1
    prsb03-dataelement-10674link
    Details of the person's stage goals
    treeblank treeblank treeblank treeblank treetree folder Outcome
    0 … 1
    prsb03-dataelement-10681link
    The outcome of the stage goal
    treeblank treeblank treetree folder Outcomes
    0 … *
    prsb03-dataelement-10416link
    Outcomes of each of the person’s goals, aims and targets. Includes comments recorded by the person, date and status.
    treetree folder Agreed with person or legitimate representative
    0 … 1
    prsb03-dataelement-10409link
    Indicates whether the plan was discussed and agreed with the person or legitimate representative.
    treetree folder Care funding source
    0 … 1
    prsb03-dataelement-10410link
    A reference to the funding source and any conditions or limitations associated.
    treetree draft  Date this plan was last updated
    0 … 1
    prsb03-dataelement-10412link
    This is a record of the date that this care and support plan was last updated.Date and time
    treetree draft  Other care planning documents
    0 … *
    prsb03-dataelement-10415link
    Reference other care planning documents, including the type, location and date.

    This may include condition-specific plans, advance care plans, end of life care plan, etc.Free text.
    treetree draft  Planned review date/interval
    0 … 1
    prsb03-dataelement-10417link
    This is the date/interval when this information will next be reviewed. SNOMED CT tag : - 425268008 | Review of care plan (procedure) |Date and time
    treetree folder Responsibility for review
    0 … 1
    prsb03-dataelement-10418link
    This is a record of who has responsibility for arranging review of this information.
    folder Contingency/safety plans
    0 … *
    prsb03-dataelement-469link
    These are the things to do and people to contact, should an individual’s health or other circumstances get worse for safety.
    treetree folder Trigger factors
    0 … *
    prsb03-dataelement-10375link
    Signs to watch out for that may indicate a significant change in health or other circumstances e.g. feeling agitated
    treetree folder Contingency plan name
    0 … 1
    prsb03-dataelement-10371link
    When the action evaluation needs to be reviewed. 
    treetree folder What should happen
    0 … *
    prsb03-dataelement-10376link
    Guidance on specific actions or interventions that may be required or should be avoided in specific situations. This may include circumstances where action needs to be taken if a carer is unable to care for the person. A statement of suggested actions. Usually expressed as: in the event of X do Y.
    treetree folder Who should be contacted
    0 … *
    prsb03-dataelement-10377link
    Who should be contacted in the event of significant problems or deterioration in health or wellbeing. e.g. name, role and contact details.
    treetree folder Agreed with person or legitimate representative
    0 … 1
    prsb03-dataelement-10369link
    Indicates whether the plan was discussed and agreed with the person or legitimate representative.
    treetree draft  Date this plan was last updated
    0 … 1
    prsb03-dataelement-10372link
    The date that this contingency plan was last updated.Date and time
    treetree draft  Planned review date/interval
    0 … 1
    prsb03-dataelement-10373link
    This is the date/interval when this contingency plan will next be reviewed. SNOMED CT tag : - 425268008 | Review of care plan (procedure) |Date and time
    treetree folder Responsibility for review
    0 … 1
    prsb03-dataelement-10374link
    This is who has responsibility for arranging review of this information.
    treetree folder Advance statement
    0 … 1
    prsb03-dataelement-10777link
    Written requests and preferences made by a person with capacity conveying their wishes, beliefs and values for their future care should they lose capacity.
    treeblank treetree folder Advance statement
    0 … 1
    prsb03-dataelement-13695link
    Does the person have an advance statement.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13696link
    The coded value for advance statementSNOMED CT: - 816281000000101 | Has advance statement (Mental Capacity Act 2005) (finding) |
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13697link
    Free text field to be used if no code is availableFree text
    treetree draft  Anticipatory medicines/equipment
    0 … *
    prsb03-dataelement-10370link
    Medicines or equipment available that may be required in specific situations and their location. A statement regarding the availability or location of the anticipatory medicines/equipment. SNOMED CT Tag : - 871021000000106 | Prescription of palliative care anticipatory medication (procedure) |Free text
    folder Additional support plans
    0 … *
    prsb03-dataelement-502link
    Additional support plans
    treetree folder Additional support plan name
    0 … 1
    prsb03-dataelement-10402link
    The name of the particular additional supporting plan, e.g. dieticians plan, wound management plan, discharge management plan and behaviour support plan.
    treetree draft  Additional support plan content
    0 … 1
    prsb03-dataelement-10403link
    This is the content of any additional care and support plan which the person and/or care professional consider should be shared with others providing care and support. May be structured in different ways, e.g. tables, diagrams, images. This is the content of any additional care and support plan which the individual and/or care professional consider should be shared with others providing care and support. It should be structured as recommended for the care and support plan and if contains additional detail, it may be referenced here.Free text
    treetree draft  Planned review date/interval
    0 … 1
    prsb03-dataelement-10405link
    This is the date/interval when this information will next be reviewed. SNOMED CT tag : - 425268008 | Review of care plan (procedure) |Date and time
    treetree folder Responsibility for review
    0 … 1
    prsb03-dataelement-10406link
    This is a record of who has responsibility for arranging review of this information. Should include their name, role and contact details.
    treetree draft  Date this plan was last updated
    0 … 1
    prsb03-dataelement-10407link
    This is a record of the date that this information was last updated.Date and time
    folder End of life care
    0 … 1
    prsb03-dataelement-10743link
    Information relating to end of life care.

    N.B. This is not an end of life care plan but contains information that would be found in an end of life care plan.
    treetree folder Cardio-pulmonary resuscitation (CPR) decision
    0 … 1
    prsb03-dataelement-10771link
    Whether a decision has been made, the decision, who made the decision, the date of decision, date for review and location of documentation. Where the person or their family member/carer have not been informed of the clinical decision please state the reason why.
    treeblank treetree folder Cardio-pulmonary resuscitation (CPR) decision
    0 … 1
    prsb03-dataelement-13686link
    The cardio-pulmonary resuscitation (CPR) decision.
    treeblank treeblank treetree draft  Coded value
    0 … 1
    prsb03-dataelement-13687link
    The coded value for CPR decision or DNACPRSNOMED CT: - 450475007 | For cardiopulmonary resuscitation (finding) |, 450476008 | Not for cardiopulmonary resuscitation (finding) |
    treeblank treeblank treetree draft  Free text
    0 … 1
    prsb03-dataelement-13688link
    Free text field to be used if no code is availableFree text
    treeblank treetree draft  Date for review
    0 … 1
    prsb03-dataelement-13705link
    The date for review of CPR decision.Date and time
    treeblank treetree draft  Location of document
    0 … 1
    prsb03-dataelement-13706link
    The location of the CPR decision documentFree text or URL
    treetree folder Estimated prognosis
    0 … 1
    prsb03-dataelement-10745link
    Details of the persons estimated prognosis
    treeblank treetree draft  Estimated prognosis
    0 … 1
    prsb03-dataelement-13691link
    Where a person is terminally ill this is a clinical judgment indicating the anticipated period of time until death e.g. last days, weeks, months or year of life.Free text
    treetree folder Awareness of prognosis
    0 … 1
    prsb03-dataelement-10775link
    Details of the persons awareness of prognosis
    treeblank treetree draft  Awareness of prognosis
    0 … 1
    prsb03-dataelement-13692link
    Description of the level of awareness the person and or their carer/family has regarding their estimated prognosis.Free text
    treetree folder Anticipatory actions
    0 … *
    prsb03-dataelement-10786link
    Details of the person's anticipatory actions
    treeblank treetree draft  Anticipatory actions
    0 … *
    prsb03-dataelement-13700link
    Guidance on specific interventions or actions that may be required or should be avoided in specific situations. A statement of anticipatory actions. Usually expressed as: in the event of X do Y.Free text
    treetree folder Anticipatory medicines/equipment
    0 … *
    prsb03-dataelement-10785link
    Details of the persons availability or location regarding their anticipatory medicines/equipment.
    treeblank treetree draft  Anticipatory medicines/equipment
    0 … 1
    prsb03-dataelement-13707link
    A statement regarding the availability or location of the anticipatory medicines/equipment.Free text
    treetree folder Preferred place of death
    0 … 1
    prsb03-dataelement-10780link
    Details of the person's preferred place of death
    treeblank treetree folder Preferred place of death 1st
    0 … 1
    prsb03-dataelement-13710link
    The preferences that a person has identified as their preferred place to die.
    treeblank treeblank treetree draft  Name of the place
    0 … 1
    prsb03-dataelement-13711link
    The name of the preferred place of deathFree text
    treeblank treeblank treetree draft  Type of place
    0 … 1
    prsb03-dataelement-13712link
    The type of preferred place of deathSCC11580 code : - 10: Hospital (Acute/Community/Other)20: Private residence21: Patient's own home22: Other private residence (eg relatives home, carers home)30: Hospice (inpatient specialist palliative care)40: Care Home50: Other (free text eg secure and detained settings)517111000000103, Preferred place of death: patient unable to express preference 517131000000106, Preferred place of death: discussion not appropriate766391000000108, Preferred place of death: patient declined discussion517161000000101, Preferred place of death: patient undecided
    treeblank treetree folder Preferred place of death 2nd
    0 … 1
    prsb03-dataelement-13716link
    The preferences that a person has identified as their preferred place to die.
    treeblank treeblank treetree draft  Name of the place
    0 … 1
    prsb03-dataelement-13717link
    The name of the preferred place of deathFree text
    treeblank treeblank treetree draft  Type of place
    0 … 1
    prsb03-dataelement-13718link
    The type of preferred place of deathSCC11580 code : - 10: Hospital (Acute/Community/Other)20: Private residence21: Patient's own home22: Other private residence (eg relatives home, carers home)30: Hospice (inpatient specialist palliative care)40: Care Home50: Other (free text eg secure and detained settings)517111000000103, Preferred place of death: patient unable to express preference 517131000000106, Preferred place of death: discussion not appropriate766391000000108, Preferred place of death: patient declined discussion517161000000101, Preferred place of death: patient undecided
    treetree folder Preferred place of care
    0 … 1
    prsb03-dataelement-10781link
    Details of the persons preferred place of care
    treeblank treetree draft  Preferred place of care
    0 … 1
    prsb03-dataelement-13719link
    The preferences that the person has identified as their preferred place to receive care.Free text
    folder Documents (including correspondence, audio and images)
    0 … 1
    prsb03-dataelement-10820link
    Details about documents related to the person.
    treetree folder Documents
    0 … *
    prsb03-dataelement-11259link
    This is the documents record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
    treeblank treetree draft  Documentation location
    0 … 1
    prsb03-dataelement-10946link
    The location of the documentFree text or URL
    treeblank treetree draft  Confidentiality
    0 … 1
    prsb03-dataelement-10942link
    The code specifying the level of confidentiality of the document. FHIR value set : - Confidentiality
    treeblank treetree draft  Class
    0 … 1
    prsb03-dataelement-10940link
    The document type e.g. report, summary, images, treatment plan, patient preferences, workflowFree text.
    treeblank treetree draft  Document title
    0 … 1
    prsb03-dataelement-10944link
    The title of the document.Free text
    treeblank treetree draft  Document name
    0 … 1
    prsb03-dataelement-10945link
    The name of the document. This should align to the PRSB document naming standard. Where the document is a KOS document this field (designated typeCode) is used to carry the DICOM Imaging procedure: This attribute shall be populated by the XDS-I Imaging Document Source from a code in the Procedure Code Sequence (0008,1032) of the performed procedure with which the document is associated. Values may be found in a suitable DICOM browserSNOMED CT: - As per the https://theprsb.org/wp-content/uploads/2018/11/Clinical-document-indexing-standards_NHS-Scotland.pdf
    treeblank treetree draft  Document MIME type
    0 … 1
    prsb03-dataelement-10949link
    MIME type of the document e.g. application, pdf, audio, jpegFree text
    treeblank treetree folder Service
    0 … 1
    prsb03-dataelement-11163link
    The high level imaging speciality code e.g. (R-3027B, SRT, “Radiology”)SNOMED CT or free text 999000381000000107 |Correspondence care setting type simple reference set (foundation metadata concept)|
    treeblank treetree draft  Comments
    0 … 1
    prsb03-dataelement-10941link
    Comments associated with the document.Free text
    treeblank treetree folder Additional information required for images.
    0 … 1
    prsb03-dataelement-12449link
    Additional information required for images.
    treeblank treeblank treetree draft  Image procedure
    0 … 1
    prsb03-dataelement-12450link
    The procedure used to capture the imageFree text Using DICOM code set https://dicom.innolitics.com/ciods
    treeblank treeblank treetree draft  Image procedure date
    0 … 1
    prsb03-dataelement-12451link
    The date and time the image procedure was performed.Date and time
    treeblank treeblank treetree folder Images
    0 … 1
    prsb03-dataelement-11158link
    treeblank treeblank treeblank treetree draft  Image capture date
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    prsb03-dataelement-11159link
    The date and time when the image was captured.Date and time
    treeblank treeblank treeblank treetree draft  Image ID
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    prsb03-dataelement-12460link
    A unique image identifier generated by the system.Free text
    treeblank treeblank treeblank treetree draft  Image location
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    prsb03-dataelement-12461link
    The URL for the imageFree text
    treeblank treeblank treetree draft  Format code
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    prsb03-dataelement-11161link
    The format code of the document which provides information on how to display the document.Free text
    treeblank treeblank treetree draft  Event code list
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    prsb03-dataelement-11160link
    The type of image (acquisition modality) and the anatomical site imaged.DICOM code
    treeblank treeblank treetree draft  Comments
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    prsb03-dataelement-12471link
    Comments associated with the imagingFree text
    cancelled arrowleft Response
    prsb03-transaction-160link
    Version / effective date 0.1 - 2020‑09‑07 16:04:15    
    Actor
    Sender (organization) General practitioner
    Receiver (organization) General practitioner
    Associations