Concept |
Card/Conf |
Id |
 |
Person demographics |
|
1 … 1 Mandatory |
prsb03-dataelement-10868 link
|
|
The person's details and contact information. |
 |
 |
Person name |
|
1 … 1 Mandatory |
prsb03-dataelement-10869 link
|
|
Details of the person's name |
|
0 … 1 |
prsb03-dataelement-13799 link
|
|
The first name(s) of the person. This includes middle names.NHS data dictionary :- Person given name
|
|
0 … 1 |
prsb03-dataelement-13800 link
|
|
The family name or surname of the personNHS data dictionary : - Person family name
|
|
0 … 1 |
prsb03-dataelement-10870 link
|
|
The name by which a person wishes to be addressed. The preferred name volunteered
by the person or a preferred name given by PDS that the person has asked to be called
by.NHS data dictionary: - Person full name
|
|
0 … 1 |
prsb03-dataelement-13089 link
|
|
Person's titleNHS data dictionary: - Person title
|
|
0 … 1 |
prsb03-dataelement-13798 link
|
|
A textual suffix that may be added to the end of a PERSON's name, for example, OBE,
MBE, BSc, JP, GMNHS data dictionary: - Person suffix
|
|
0 … 1 |
prsb03-dataelement-13801 link
|
|
The full name of the person in text representation.NHS data dictionary :- Person full name
|
 |
|
Date of birth |
|
1 … 1 Mandatory |
prsb03-dataelement-10871 link
|
|
The date of birth of the person.NHS data dictionary:- Person birth date
|
 |
|
Gender |
|
0 … 1 |
prsb03-dataelement-10872 link
|
|
The person's stated gender.NHS data dictionary :- Person stated gender code
|
 |
|
Ethnicity |
|
0 … 1 |
prsb03-dataelement-10874 link
|
|
The ethnicity of the person as specified by the person.NHS data dictionary :- Ethnic category
|
 |
|
Religion |
|
0 … 1 |
prsb03-dataelement-10876 link
|
|
The religious affiliation as specified by the person.
SNOMED_CT:- Religion
|
 |
|
Sex |
|
0 … 1 |
prsb03-dataelement-10877 link
|
|
The person’s phenotypic sex. Determines how the person will be treated clinically.NHS data dictionary: - person phenotypic sex
|
 |
|
NHS number |
|
0 … 1 |
prsb03-dataelement-10879 link
|
|
The unique identifier for a person within the NHS in England and Wales.NHS data dictionary:- NHS number
|
 |
|
NHS number status indicator |
|
0 … 1 |
prsb03-dataelement-13297 link
|
|
Provides an indication of the reliability of an NHS Number.NHS data dictionary :- NHS number status indicator
|
 |
|
Other identifier |
|
0 … * |
prsb03-dataelement-10880 link
|
|
Country specific or local identifier, e.g. Community Health Index (CHI) in Scotland.
NHS data dictionary: - Local patient identifier(extended), Health and care number
(NI only), Community health index number (Scotland only)
|
 |
 |
Person's address |
|
1 … * Mandatory |
prsb03-dataelement-10881 link
|
|
Person’s usual place of residence, and where relevant temporary and correspondence
addresses.
|
|
0 … 1 |
prsb03-dataelement-13082 link
|
|
Person's first line of address.
NHS data dictionary :- Address line 1
|
|
0 … 1 |
prsb03-dataelement-13083 link
|
|
Person's second line of address.
NHS data dictionary :- Address line 2
|
|
0 … 1 |
prsb03-dataelement-13084 link
|
|
Person's third line of address.
NHS data dictionary : - Address line 3
|
|
0 … 1 |
prsb03-dataelement-13085 link
|
|
Person's fourth line of address.
NHS data dictionary : - Address line 4
|
|
0 … 1 |
prsb03-dataelement-13086 link
|
|
Person's fifth line of address.NHS data dictionary : - Address line 5
|
|
0 … 1 |
prsb03-dataelement-13087 link
|
|
The person's postcode.NHS data dictionary :- Postcode of usual address
|
|
0 … 1 |
prsb03-dataelement-13221 link
|
|
The type of address e.g. Main address, Temp addressNHS data dictionary : - Address association type
|
 |
 |
Person's contact details |
|
0 … 1 |
prsb03-dataelement-13804 link
|
|
Details of the person's contact information. |
|
0 … 1 |
prsb03-dataelement-10886 link
|
|
Preferred contact method, e.g. email, letter, phone, text message etc.NHS data dictionary :- Communication contact method
|
 |
 |
 |
Person's telephone number details |
|
0 … * |
prsb03-dataelement-10883 link
|
|
The person's telephone number details |
 |
 |
 |
|
Person's telephone number |
|
0 … 1 |
prsb03-dataelement-13808 link
|
|
The person's telephone numberNHS data dictionary : - UK telephone number
|
 |
 |
 |
|
Person's telephone number type |
|
0 … 1 |
prsb03-dataelement-13805 link
|
|
The contact type e.g. home, mobileFHIR value set: - Contact point use
|
 |
 |
 |
|
Preference of telephone number |
|
0 … 1 |
prsb03-dataelement-13809 link
|
|
The preferred order of use for the telephone numberPreference of use 1-5, 1 being the highest. |
 |
 |
 |
Person's email address details |
|
0 … * |
prsb03-dataelement-13807 link
|
|
Details of the person's email address |
|
0 … 1 |
prsb03-dataelement-10882 link
|
|
Email address of the person.NHS data dictionary :- Contact email address
|
 |
 |
 |
|
Person's email address type |
|
0 … 1 |
prsb03-dataelement-13811 link
|
|
The type of email address, home, workFHIR value set: - Contact point use
|
 |
 |
 |
|
Preference of email address |
|
0 … 1 |
prsb03-dataelement-13810 link
|
|
The preferred order of use of email addressPreference of use 1-5, 1 being the highest. |
 |
 |
|
Other contact information |
|
0 … 1 |
prsb03-dataelement-13806 link
|
|
Contact details via fax, sms, urlNHS data dictionary:- Communication contact string
|
 |
|
Organ and tissue donation |
|
0 … 1 |
prsb03-dataelement-13847 link
|
|
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
|
 |
|
Educational establishment |
|
0 … 1 |
prsb03-dataelement-10911 link
|
|
If the person is a child, name and address of where the child attends, eg play group,
nursery, school.Free text or ODS code where available.
|
 |
GP practice |
|
1 … 1 Mandatory |
prsb03-dataelement-101 link
|
|
Details of the person's GP practice. |
 |
 |
GP practice record entry |
|
0 … * |
prsb03-dataelement-10643 link
|
|
This is an GP practice record entry. There may be 0 to many record entries under a
section. Each record entry is made up of a number of elements or data items
|
|
0 … 1 |
prsb03-dataelement-10003 link
|
|
The name of the person's GP. If the person is registered with a GP practice, their
usual GP name will be something volunteered by the person or their representative.Free text
|
|
0 … 1 |
prsb03-dataelement-10002 link
|
|
Name and address of the person's registered GP practice Registered GP practice details
are available from the Person Demographics Service (PDS), or volunteered from the
person or their representative. Include details of the practice name and address.Free text
|
|
1 … 1 Mandatory |
prsb03-dataelement-10001 link
|
|
The identifier of the registered GP practice.
NHS data dictionary : - General medical practice code (patient registration)
|
 |
Safeguarding |
|
0 … 1 |
prsb03-dataelement-271 link
|
|
The safeguarding details of the person. |
 |
 |
Safeguarding concerns |
|
0 … * |
prsb03-dataelement-10821 link
|
|
Details of safeguarding concerns |
|
0 … 1 |
prsb03-dataelement-13428 link
|
|
Indicates whether or not the hospital considers that there are safeguarding issues
associated with the patient.Flag: No =N: Yes = Y
|
 |
 |
|
Safeguarding concerns date |
|
0 … 1 |
prsb03-dataelement-10172 link
|
|
The date the safeguarding concerns were identified.Date and time |
 |
 |
|
Safeguarding concerns end date |
|
0 … 1 |
prsb03-dataelement-10766 link
|
|
The date safeguarding concerns ended.Date and time |
|
0 … 1 |
prsb03-dataelement-10173 link
|
|
The location where the safeguarding concerns were identified. |
|
0 … 1 |
prsb03-dataelement-13437 link
|
|
The coded value of locationNHS data dictionary : - Organisation code
|
|
0 … 1 |
prsb03-dataelement-13438 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … * |
prsb03-dataelement-10171 link
|
|
Identified safeguarding concerns. |
|
0 … 1 |
prsb03-dataelement-13756 link
|
|
The coded value for safeguarding concernsSNOMED CT : - ^999002381000000108 | Safeguarding issues simple reference set (foundation
metadata concept) |
|
|
0 … 1 |
prsb03-dataelement-13757 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-11358 link
|
|
The professional who identified the safeguarding concerns. |
|
0 … 1 |
prsb03-dataelement-11359 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-11360 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
0 … 1 |
prsb03-dataelement-11361 link
|
|
The grade of the professional.Free text |
|
0 … 1 |
prsb03-dataelement-11362 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-11363 link
|
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-11364 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-11365 link
|
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
0 … 1 |
prsb03-dataelement-11366 link
|
|
Details of the person completing the record. |
|
0 … 1 |
prsb03-dataelement-11367 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-11368 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-11369 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-11370 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-11371 link
|
|
The organisation the person completing the record works for.
NHS data dictionary : -
Organisation data service
|
|
0 … 1 |
prsb03-dataelement-11372 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-11373 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-11374 link
|
|
Contact details of the person completing the record.
NHS data dictionary : - UK telephone number
|
|
0 … 1 |
prsb03-dataelement-10175 link
|
|
Further details on safeguarding concerns.Free text |
 |
Referral details |
|
0 … 1 |
prsb03-dataelement-105 link
|
|
The details of the referral. |
 |
 |
Referral details record entry |
|
0 … * |
prsb03-dataelement-10917 link
|
|
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.
|
|
0 … 1 |
prsb03-dataelement-10006 link
|
|
The date of referralDate and time |
|
1 … 1 Mandatory |
prsb03-dataelement-10005 link
|
|
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.
|
|
0 … 1 |
prsb03-dataelement-10971 link
|
|
The name of the referrer.Free text |
|
0 … 1 |
prsb03-dataelement-10972 link
|
|
Role of the referrer.FHIR value set : - sdsjobrole
|
|
0 … 1 |
prsb03-dataelement-10973 link
|
|
The grade of the referrer.Free text |
|
0 … 1 |
prsb03-dataelement-12409 link
|
|
The team or department of the referrer.Free text |
|
0 … 1 |
prsb03-dataelement-12410 link
|
|
The specialty of the referrer.NHS data dictionary - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-12411 link
|
|
The service of the referrer. |
|
0 … 1 |
prsb03-dataelement-13397 link
|
|
The coded value for serviceSNOMED CT: - 1127531000000102 |Services simple reference set (foundation metadata
concept)|
|
|
0 … 1 |
prsb03-dataelement-13398 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-10974 link
|
|
The organisation of the referrer. |
|
0 … 1 |
prsb03-dataelement-13399 link
|
|
The coded value for organisation codeNHS data dictionary : - Organisation data service
|
|
0 … 1 |
prsb03-dataelement-13400 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-10975 link
|
|
The contact details of the referrer.Free text |
 |
Contacts with professionals |
|
1 … 1 Mandatory |
prsb03-dataelement-169 link
|
|
The details of the person’s contact with a professional. |
 |
 |
Contacts with professionals record entry |
|
1 … * Mandatory |
prsb03-dataelement-10718 link
|
|
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.
|
|
1 … 1 Mandatory |
prsb03-dataelement-10069 link
|
|
Date and time of the contact.Date and time. |
 |
Discharge details |
|
1 … 1 |
prsb03-dataelement-191 link
|
|
Discharge details |
 |
 |
Discharge details record entry |
|
0 … * |
prsb03-dataelement-10919 link
|
|
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.
|
|
1 … 1 Mandatory |
prsb03-dataelement-10096 link
|
|
The date and time of dischargeDate and time |
|
1 … 1 Mandatory |
prsb03-dataelement-10091 link
|
|
The destination of the person on discharge. Sent as per the ECDS Emergency Care Discharge
Destination code set (SNOMED CT).SNOMED CT
|
|
1 … 1 Mandatory |
prsb03-dataelement-10092 link
|
|
Patient status on discharge from emergency care. Sent as per the ECDS Emergency Care
DischargeStatus code set (SNOMED CT)SNOMED CT
|
 |
Presenting complaints or issues |
|
1 … 1 Mandatory |
prsb03-dataelement-210 link
|
|
Presenting complaints or issues |
 |
 |
Presenting complaint or issue |
|
1 … 1 Mandatory |
prsb03-dataelement-13784 link
|
|
The health problem or issue experienced by the person resulting in their attendance.
This may include disease state, medical condition, response and reactions to therapies.
e.g., blackout, dizziness, chest pain, follow up from admission, falls, a specific
procedure, investigation or treatment.
|
|
0 … 1 |
prsb03-dataelement-13785 link
|
|
The coded value for presenting complaint or issueSNOMED CT : - ^1127581000000103 |Health issues simple reference set|
|
|
0 … 1 |
prsb03-dataelement-13786 link
|
|
Free text |
 |
Problem list |
|
1 … 1 Mandatory |
prsb03-dataelement-10927 link
|
|
A summary of the problems that require investigation or treatment. |
 |
 |
Problem list record entry |
|
0 … * |
prsb03-dataelement-10928 link
|
|
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.
|
|
0 … 1 |
prsb03-dataelement-10929 link
|
|
The date the problem was identified.Date and time |
|
0 … 1 |
prsb03-dataelement-12133 link
|
|
The professional who identified the problem. |
|
0 … 1 |
prsb03-dataelement-12134 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-12135 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
0 … 1 |
prsb03-dataelement-12136 link
|
|
The grade of the professional.Free text |
|
0 … 1 |
prsb03-dataelement-12137 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-12138 link
|
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-12139 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-12140 link
|
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
0 … 1 |
prsb03-dataelement-10931 link
|
|
The location the problem was identified. |
|
0 … 1 |
prsb03-dataelement-13242 link
|
|
The coded value for location.NHS data dictionary : - Organisation data service code
|
|
0 … 1 |
prsb03-dataelement-13243 link
|
|
Free text field to be used if no code is availableFree text |
|
1 … 1 Mandatory |
prsb03-dataelement-10932 link
|
|
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
|
|
0 … 1 |
prsb03-dataelement-13244 link
|
|
The coded value for the problem list.SNOMED CT : - ^1127581000000103 |Health issues simple reference set|
|
|
0 … 1 |
prsb03-dataelement-13245 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-10933 link
|
|
A date or estimated date that the problem beganDate and time |
|
0 … 1 |
prsb03-dataelement-10934 link
|
|
The date or estimated date the problem was resolved.Date and time. |
|
0 … 1 |
prsb03-dataelement-14262 link
|
|
PLACEHOLDER: The main problem or diagnosis on discharge.
Problems may include diagnoses, symptoms, disabilities and social or behavioural issues,
and comprise the ‘Problem list’
|
|
0 … 1 |
prsb03-dataelement-14263 link
|
|
The coded value for the problem list.SNOMED CT : - ^1127581000000103 |Health issues simple reference set|
|
|
0 … 1 |
prsb03-dataelement-14264 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-10935 link
|
|
The stage of the disease where relevant.Free text |
|
0 … 1 |
prsb03-dataelement-12141 link
|
|
Details of the person completing the record. |
|
0 … 1 |
prsb03-dataelement-12142 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-12143 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-12144 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-12145 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-12146 link
|
|
The organisation the person completing the record works for.
NHS data dictionary : -
Organisation data service
|
|
0 … 1 |
prsb03-dataelement-12147 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-12148 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-12149 link
|
|
Contact details of the person completing the record.
NHS data dictionary : - UK telephone number
|
|
0 … * |
prsb03-dataelement-10936 link
|
|
Supporting text may be given covering the problem.Free text |
 |
Procedures and therapies |
|
0 … 1 |
prsb03-dataelement-238 link
|
|
The details of any procedures performed. Includes both psychological and medical therapies
and procedures (e.g. cognitive behaviour therapy, hip replacement)
|
 |
 |
Procedure record entry |
|
0 … * |
prsb03-dataelement-10652 link
|
|
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.
|
|
0 … 1 |
prsb03-dataelement-10138 link
|
|
The date the procedure was performed.Date and time. |
|
0 … 1 |
prsb03-dataelement-13246 link
|
|
The location where the procedure was undertaken. |
|
0 … 1 |
prsb03-dataelement-13247 link
|
|
The coded value for location.NHS data dictionary : - Organisation data service code
|
|
0 … 1 |
prsb03-dataelement-13248 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-12150 link
|
|
The professional who performed the procedure. |
|
0 … 1 |
prsb03-dataelement-12151 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-12152 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
0 … 1 |
prsb03-dataelement-12153 link
|
|
The grade of the professional.Free text |
|
0 … 1 |
prsb03-dataelement-12154 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-12155 link
|
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-12156 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-12157 link
|
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
1 … 1 Mandatory |
prsb03-dataelement-10141 link
|
|
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.
|
|
0 … 1 |
prsb03-dataelement-13249 link
|
|
The procedure code.SNOMED CT : - <<71388002 |Procedure| OR <<129125009 |Procedure with explicit context| |
|
0 … 1 |
prsb03-dataelement-13250 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-10142 link
|
|
The body site of the procedure |
|
0 … 1 |
prsb03-dataelement-13251 link
|
|
The coded value of the anatomical site.SNOMED CT :- <123037004 |Body structure (body structure)| |
|
0 … 1 |
prsb03-dataelement-13252 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-10143 link
|
|
Laterality of the procedure |
|
0 … 1 |
prsb03-dataelement-13253 link
|
|
The coded value for laterality.SNOMED CT:- <182353008 |Side (qualifier value)| |
|
0 … 1 |
prsb03-dataelement-13254 link
|
|
Free text field to be used if no code is availableFree text |
 |
 |
 |
Complications related to procedure |
|
0 … 1 |
prsb03-dataelement-10144 link
|
|
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.
|
|
0 … 1 |
prsb03-dataelement-13255 link
|
|
The coded value for complications relating to procedure.SNOMED CT : - <404684003 |Clinical finding (finding)|
|
|
0 … 1 |
prsb03-dataelement-13256 link
|
|
Free text field to be used if no code is availableFree text |
 |
 |
 |
Specific anesthesia issues |
|
0 … 1 |
prsb03-dataelement-10145 link
|
|
Details of any adverse reaction to any anesthetic agents including local anesthesia.
Problematic intubation, transfusion reaction, etc.
|
|
0 … 1 |
prsb03-dataelement-13257 link
|
|
The coded value for specific anesthesia issues.SNOMED CT |
|
0 … 1 |
prsb03-dataelement-13258 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-12158 link
|
|
Details of the person completing the record. |
|
0 … 1 |
prsb03-dataelement-12159 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-12160 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-12161 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-12162 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-12163 link
|
|
The organisation the person completing the record works for.
NHS data dictionary : -
Organisation data service
|
|
0 … 1 |
prsb03-dataelement-12164 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-12165 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-12166 link
|
|
Contact details of the person completing the record.
NHS data dictionary : - UK telephone number
|
|
0 … 1 |
prsb03-dataelement-10146 link
|
|
Any further textual comment to clarify such as statement that information is partial
or incomplete. Also indicate the outcome of the procedure.Free text
|
 |
Clinical Summary |
|
1 … 1 Mandatory |
prsb03-dataelement-247 link
|
|
Clinical Summary |
 |
|
Clinical summary |
|
1 … 1 Mandatory |
prsb03-dataelement-10147 link
|
|
Summary of the encounter. Where possible, very brief. This may include interpretation
of findings and results; differential diagnoses, opinion and specific action(s). Planned
actions will be recorded under ‘plan’.Free text
|
 |
Risks |
|
0 … 1 |
prsb03-dataelement-276 link
|
|
Details of any risks related to the person. |
 |
 |
Risks to self |
|
0 … * |
prsb03-dataelement-10176 link
|
|
Details of the persons risk to self |
|
0 … 1 |
prsb03-dataelement-11893 link
|
|
The start date of the risk.Date and time |
|
0 … 1 |
prsb03-dataelement-11894 link
|
|
The date the risk ended.Date and time |
|
0 … 1 |
prsb03-dataelement-13579 link
|
|
Risks the person poses to themselves, e.g. suicide, overdose, self-harm, self-neglect.SNOMED CT: - <281694009 |Finding of at risk (finding)|
|
|
0 … 1 |
prsb03-dataelement-11895 link
|
|
The location where the risk was identified. |
|
0 … 1 |
prsb03-dataelement-13586 link
|
|
The coded value for locationNHS data dictionary : - Organisation service code
|
|
0 … 1 |
prsb03-dataelement-13587 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-11896 link
|
|
The professional who identified the risk. |
|
0 … 1 |
prsb03-dataelement-11897 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-11898 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
0 … 1 |
prsb03-dataelement-11899 link
|
|
The grade of the professional.Free text |
|
0 … 1 |
prsb03-dataelement-11900 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-11901 link
|
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-11902 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-11903 link
|
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
0 … 1 |
prsb03-dataelement-11904 link
|
|
Details of the person completing the record. |
|
0 … 1 |
prsb03-dataelement-11905 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-11906 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-11907 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-11908 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-11909 link
|
|
The organisation the person completing the record works for.
NHS data dictionary : -
Organisation data service
|
|
0 … 1 |
prsb03-dataelement-11910 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-11911 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-11912 link
|
|
Contact details of the person completing the record.
NHS data dictionary : - UK telephone number
|
 |
 |
Risks to others |
|
0 … * |
prsb03-dataelement-10177 link
|
|
Details of the person's risk to others |
|
0 … 1 |
prsb03-dataelement-11913 link
|
|
The start date of the risk.Date and time |
|
0 … 1 |
prsb03-dataelement-11914 link
|
|
The date the risk ended.Date and time |
|
0 … 1 |
prsb03-dataelement-13580 link
|
|
Risks to professionals or others.SNOMED CT: - <<391155006 |At risk of harming others (finding)|
|
|
0 … 1 |
prsb03-dataelement-11915 link
|
|
The location where the risk to others was identified. |
|
0 … 1 |
prsb03-dataelement-13588 link
|
|
The coded value for locationNHS data dictionary : - Organisation data service
|
|
0 … 1 |
prsb03-dataelement-13589 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-11916 link
|
|
The professional who identifies the risk to others. |
|
0 … 1 |
prsb03-dataelement-11917 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-11918 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
0 … 1 |
prsb03-dataelement-11919 link
|
|
The grade of the professional.Free text |
|
0 … 1 |
prsb03-dataelement-11920 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-11921 link
|
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-11922 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-11923 link
|
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
0 … 1 |
prsb03-dataelement-11924 link
|
|
Details of the person completing the record. |
|
0 … 1 |
prsb03-dataelement-11925 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-11926 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-11927 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-11928 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-11929 link
|
|
The organisation the person completing the record works for.
NHS data dictionary : -
Organisation data service
|
|
0 … 1 |
prsb03-dataelement-11930 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-11931 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-11932 link
|
|
Contact details of the person completing the record.
NHS data dictionary : - UK telephone number
|
 |
 |
Risk from others |
|
0 … * |
prsb03-dataelement-10178 link
|
|
Risks to the person from an identified individual e.g. family member etc.Free Text. |
|
0 … 1 |
prsb03-dataelement-11933 link
|
|
The start date of the risk.Date and time |
|
0 … 1 |
prsb03-dataelement-11934 link
|
|
The date the risk ended.Date and time |
|
0 … 1 |
prsb03-dataelement-13581 link
|
|
Risks to the person from an identified individual e.g. family member etc.SNOMED CT: - <281694009 |Finding of at risk (finding)|
|
|
0 … 1 |
prsb03-dataelement-11935 link
|
|
The location where the risk from others was identified. |
|
0 … 1 |
prsb03-dataelement-13590 link
|
|
The coded value for locationNHS data dictionary : - Organisation data service
|
|
0 … 1 |
prsb03-dataelement-13591 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-11936 link
|
|
The professional who identified the risk from others. |
|
0 … 1 |
prsb03-dataelement-11937 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-11938 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
0 … 1 |
prsb03-dataelement-11939 link
|
|
The grade of the professional.Free text |
|
0 … 1 |
prsb03-dataelement-11940 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-11941 link
|
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-11942 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-11943 link
|
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
0 … 1 |
prsb03-dataelement-11944 link
|
|
Details of the person completing the record. |
|
0 … 1 |
prsb03-dataelement-11945 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-11946 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-11947 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-11948 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-11949 link
|
|
The organisation the person completing the record works for.
NHS data dictionary : -
Organisation data service
|
|
0 … 1 |
prsb03-dataelement-11950 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-11951 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-11952 link
|
|
Contact details of the person completing the record.
NHS data dictionary : - UK telephone number
|
 |
 |
Risk of accidents |
|
0 … * |
prsb03-dataelement-10751 link
|
|
Details of the risks the person poses to themselves from accidents. |
|
0 … 1 |
prsb03-dataelement-11953 link
|
|
The start date of the risk.Date and time |
|
0 … 1 |
prsb03-dataelement-11954 link
|
|
The date the risk ended.Date and time |
|
0 … 1 |
prsb03-dataelement-13582 link
|
|
Risks the person poses to themselves from accidents.Free text |
|
0 … 1 |
prsb03-dataelement-11955 link
|
|
The location where the risk of accidents was identified. |
|
0 … 1 |
prsb03-dataelement-13592 link
|
|
The coded value for locationNHS data dictionary : - Organisation data service
|
|
0 … 1 |
prsb03-dataelement-13593 link
|
|
Free text field to be used if no coded text available |
|
0 … 1 |
prsb03-dataelement-11956 link
|
|
The professional who identified the risk of accidents. |
|
0 … 1 |
prsb03-dataelement-11957 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-11958 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
0 … 1 |
prsb03-dataelement-11959 link
|
|
The grade of the professional.Free text |
|
0 … 1 |
prsb03-dataelement-11960 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-11961 link
|
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-11962 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-11963 link
|
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
0 … 1 |
prsb03-dataelement-11964 link
|
|
Details of the person completing the record. |
|
0 … 1 |
prsb03-dataelement-11965 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-11966 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-11967 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-11968 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-11969 link
|
|
The organisation the person completing the record works for.
NHS data dictionary : -
Organisation data service
|
|
0 … 1 |
prsb03-dataelement-11970 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-11971 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-11972 link
|
|
Contact details of the person completing the record.
NHS data dictionary : - UK telephone number
|
 |
 |
Other risks |
|
0 … * |
prsb03-dataelement-10802 link
|
|
Details of other risks, factors or behaviours relating to the person. |
|
0 … 1 |
prsb03-dataelement-11973 link
|
|
The start date of the risk.Date and time |
|
0 … 1 |
prsb03-dataelement-11974 link
|
|
The date the risk ended.Date and time |
|
0 … 1 |
prsb03-dataelement-13583 link
|
|
Other risks, factors or behaviours relating to the person.Free text |
|
0 … 1 |
prsb03-dataelement-11975 link
|
|
The location where the other risks were identified. |
|
0 … 1 |
prsb03-dataelement-13594 link
|
|
The coded value for locationNHS data dictionary : - Organisation data service
|
|
0 … 1 |
prsb03-dataelement-13595 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-11976 link
|
|
The professional who identified the other risks. |
|
0 … 1 |
prsb03-dataelement-11977 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-11978 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
0 … 1 |
prsb03-dataelement-11979 link
|
|
The grade of the professional.Free text |
|
0 … 1 |
prsb03-dataelement-11980 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-11981 link
|
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-11982 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-11983 link
|
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
0 … 1 |
prsb03-dataelement-11984 link
|
|
Details of the person completing the record. |
|
0 … 1 |
prsb03-dataelement-11985 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-11986 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-11987 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-11988 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-11989 link
|
|
The organisation the person completing the record works for.
NHS data dictionary : -
Organisation data service
|
|
0 … 1 |
prsb03-dataelement-11990 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-11991 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-11992 link
|
|
Contact details of the person completing the record.
NHS data dictionary : - UK telephone number
|
 |
Allergies and adverse reactions |
|
1 … 1 |
prsb03-dataelement-282 link
|
|
Allergies and adverse reactions |
 |
 |
Allergies and adverse reactions record entry |
|
0 … * |
prsb03-dataelement-10657 link
|
|
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.
|
|
0 … 1 |
prsb03-dataelement-10186 link
|
|
The type of reaction experienced by the person (allergic, adverse, intolerance)FHIR value set :- Allergy, Intolerance
|
|
1 … 1 Mandatory |
prsb03-dataelement-10182 link
|
|
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”
|
|
0 … 1 |
prsb03-dataelement-13441 link
|
|
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)
|
|
0 … 1 |
prsb03-dataelement-13442 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … * |
prsb03-dataelement-10658 link
|
|
Details of the reaction. |
|
0 … 1 |
prsb03-dataelement-10190 link
|
|
The date that the reaction was identified.Date and time |
|
0 … 1 |
prsb03-dataelement-10846 link
|
|
Details of where the allergy was identified. Linked to the date of the diagnosis by
the professional.
|
|
0 … 1 |
prsb03-dataelement-13439 link
|
|
The coded value for location.NHS data dictionary : - Organisation data service
|
|
0 … 1 |
prsb03-dataelement-13440 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-11665 link
|
|
The substance, or a class of substances, that is considered to be responsible for
the adverse reaction.
|
|
0 … 1 |
prsb03-dataelement-13554 link
|
|
The coded value for substanceSNOMED CT : - <105590001 | Substance (substance) | or <373873005 | Pharmaceutical
/ biologic product (product) |
|
|
0 … 1 |
prsb03-dataelement-13555 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-10183 link
|
|
A description of the manifestation of the allergic or adverse reaction experienced
by the person. For example, skin rash.
|
|
0 … 1 |
prsb03-dataelement-13556 link
|
|
The coded value for description of reaction.SNOMED CT: - ^1127581000000103 |Health issues simple reference set| |
|
0 … 1 |
prsb03-dataelement-13557 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-13844 link
|
|
Date and time when manifestations showed e.g could be at home a few days earlier than
the contactDate and time
|
|
0 … 1 |
prsb03-dataelement-10184 link
|
|
A description of the severity of the reaction. |
|
0 … 1 |
prsb03-dataelement-13558 link
|
|
The coded value for severityFHIR value set : - Severity
|
|
0 … 1 |
prsb03-dataelement-13559 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-10185 link
|
|
A description of the certainty that the stated causative agent caused the allergic
or adverse reaction.
|
|
0 … 1 |
prsb03-dataelement-13560 link
|
|
The coded value for certainty.FHIR value set : - Certainty
|
|
0 … 1 |
prsb03-dataelement-13561 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-13856 link
|
|
The route the person was exposed to the substance |
|
0 … 1 |
prsb03-dataelement-13857 link
|
|
The coded value for route of exposureSNOMED CT: - ^999000051000001100 |ePrescribing route of administration simple reference
set|
|
|
0 … 1 |
prsb03-dataelement-13858 link
|
|
Free text field to be used if no coded text available |
|
0 … 1 |
prsb03-dataelement-10189 link
|
|
Any additional comment or clarification about the adverse reaction.Free text |
|
0 … 1 |
prsb03-dataelement-10187 link
|
|
Results of investigations that confirmed the certainty of the diagnosis. Examples
might include results of skin prick allergy testsFree text
|
|
0 … 1 |
prsb03-dataelement-10188 link
|
|
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
|
|
0 … 1 |
prsb03-dataelement-14253 link
|
|
The date the allergy was diagnosed as endedDate and time |
|
0 … 1 |
prsb03-dataelement-14273 link
|
|
Any further comments on the person's allergies or adverse reactions.Free text |
|
0 … 1 |
prsb03-dataelement-12010 link
|
|
The professional who identified the reaction. |
|
0 … 1 |
prsb03-dataelement-12011 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-12012 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
0 … 1 |
prsb03-dataelement-12013 link
|
|
The grade of the professional.Free text |
|
0 … 1 |
prsb03-dataelement-12014 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-12015 link
|
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-12016 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-12017 link
|
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
0 … 1 |
prsb03-dataelement-12018 link
|
|
Details of the person completing the record. |
|
0 … 1 |
prsb03-dataelement-12019 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-12020 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-12021 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-12022 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-12023 link
|
|
The organisation the person completing the record works for.
NHS data dictionary : -
Organisation data service
|
|
0 … 1 |
prsb03-dataelement-12024 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-12025 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-12026 link
|
|
Contact details of the person completing the record.
NHS data dictionary : - UK telephone number
|
 |
Medications and medical devices |
|
0 … 1 |
prsb03-dataelement-636 link
|
|
Medications and medical devices |
 |
 |
Medication item entry |
|
0 … * |
prsb03-dataelement-10663 link
|
|
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.
|
|
0 … 1 |
prsb03-dataelement-10664 link
|
|
Medication item cluster |
|
0 … 1 |
prsb03-dataelement-10843 link
|
|
The date on which the medication or medical device was prescribed.Date and time |
|
0 … 1 |
prsb03-dataelement-10844 link
|
|
The location where the medication or the medical device was prescribed. |
|
0 … 1 |
prsb03-dataelement-13620 link
|
|
The coded value for locationNHS data dictionary : - Organisation data service
|
|
0 … 1 |
prsb03-dataelement-13621 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-12002 link
|
|
The professional who prescribed the medication or medical device. |
|
0 … 1 |
prsb03-dataelement-12003 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-12004 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
0 … 1 |
prsb03-dataelement-12005 link
|
|
The grade of the professional.Free text |
|
0 … 1 |
prsb03-dataelement-12006 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-12007 link
|
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-12008 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-12009 link
|
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
1 … 1 Mandatory |
prsb03-dataelement-10536 link
|
|
May be generic name or brand name. |
|
0 … 1 |
prsb03-dataelement-13622 link
|
|
The coded value for medication namedm+d:- any code from the VTM, VMP, AMP, VMPP and AMPP concept classes |
|
0 … 1 |
prsb03-dataelement-13623 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-10537 link
|
|
The form of the medication e.g. capsule, drops, tablet, lotion etc. |
|
0 … 1 |
prsb03-dataelement-13624 link
|
|
The coded value for form.SNOMED CT: - ^999000781000001107 | National Health Service dictionary of medicines
and devices dose form simple reference set (foundation metadata concept) |
|
|
0 … 1 |
prsb03-dataelement-13625 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-10538 link
|
|
The route by which the medication is administered e.g. oral, IM, IV |
|
0 … 1 |
prsb03-dataelement-13655 link
|
|
The coded value for routeSNOMED CT: - ^999000051000001100 |ePrescribing route of administration simple reference
set (foundation metadata concept)|
|
|
0 … 1 |
prsb03-dataelement-13656 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-10540 link
|
|
The anatomical site at which the medication is to be administered. |
|
0 … 1 |
prsb03-dataelement-13657 link
|
|
The coded value for siteSNOMED CT: - <442083009 | Anatomical or acquired body structure (body structure) |
|
|
0 … 1 |
prsb03-dataelement-13658 link
|
|
Free text field to be used when code is not availableFree text |
|
0 … 1 |
prsb03-dataelement-10541 link
|
|
The technique or method by which the medication is to be administered. |
 |
 |
 |
|
Over the counter medication flag |
|
0 … 1 |
prsb03-dataelement-13379 link
|
|
Indicates if the medication or device is acquired without a prescription i.e. got
by the person over the counterFlag : - Yes or No
|
 |
 |
 |
 |
Structured dose direction cluster |
|
0 … 1 |
prsb03-dataelement-11639 link
|
|
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.
|
|
0 … 1 |
prsb03-dataelement-10554 link
|
|
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
|
|
0 … 1 |
prsb03-dataelement-10555 link
|
|
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
|
|
0 … 1 |
prsb03-dataelement-10548 link
|
|
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
|
 |
 |
 |
 |
|
Dose directions description |
|
0 … 1 |
prsb03-dataelement-10544 link
|
|
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
|
|
0 … 1 |
prsb03-dataelement-10545 link
|
|
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
|
|
0 … 1 |
prsb03-dataelement-10561 link
|
|
Details of the overall course of medication. |
|
0 … 1 |
prsb03-dataelement-10666 link
|
|
The status of this prescription.FHIR value set : - Medication status
|
|
0 … 1 |
prsb03-dataelement-10546 link
|
|
Reason for medication being prescribed, where known.Free text |
|
0 … 1 |
prsb03-dataelement-10667 link
|
|
The date and/or time that the medication course should begin.Date and time |
|
0 … 1 |
prsb03-dataelement-10557 link
|
|
The date and/or time that the medication course should finish.Date and time |
 |
 |
 |
 |
|
Link to indication record |
|
0 … 1 |
prsb03-dataelement-10668 link
|
|
A link to the record which contains the indication for this medication order.Free text with URL |
|
0 … 1 |
prsb03-dataelement-10547 link
|
|
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
|
 |
 |
 |
 |
Medication change summary cluster |
|
0 … 1 |
prsb03-dataelement-10568 link
|
|
Records the changes made to medication. |
|
0 … 1 |
prsb03-dataelement-10669 link
|
|
The nature of any change made to the medication.FHIR value set : Medication status
|
|
0 … 1 |
prsb03-dataelement-10670 link
|
|
Reason for change in medication, e.g. sub-therapeutic dose, person intolerant.
SNOMED CT:- ^1127601000000107 | Healthcare matters simple reference set (foundation
metadata concept) |
|
|
0 … 1 |
prsb03-dataelement-10671 link
|
|
The date of the change - addition, or amendmentDate and time |
|
0 … 1 |
prsb03-dataelement-10672 link
|
|
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
|
 |
 |
 |
|
Total dose daily quantity |
|
0 … 1 |
prsb03-dataelement-10665 link
|
|
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
|
|
0 … 1 |
prsb03-dataelement-11993 link
|
|
Details of the person completing the record. |
|
0 … 1 |
prsb03-dataelement-11994 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-11995 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-11996 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-11997 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-11998 link
|
|
The organisation the person completing the record works for.
NHS data dictionary : -
Organisation data service
|
|
0 … 1 |
prsb03-dataelement-11999 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-12000 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-12001 link
|
|
Contact details of the person completing the record.
NHS data dictionary : - UK telephone number
|
|
0 … * |
prsb03-dataelement-10583 link
|
|
Medical devices |
|
0 … 1 |
prsb03-dataelement-10673 link
|
|
Any medical device that isn't prescribed.Free text |
|
0 … 1 |
prsb03-dataelement-11280 link
|
|
Any information regarding the medical device.Free text |
 |
 |
 |
Medication discontinued entry |
|
0 … * |
prsb03-dataelement-10576 link
|
|
Medication discontinued entry |
 |
 |
 |
 |
Name of discontinued medication |
|
1 … 1 Mandatory |
prsb03-dataelement-10577 link
|
|
The name of the medication or medical device being discontinued |
|
0 … 1 |
prsb03-dataelement-13659 link
|
|
The coded value for medication name
dm+d:- any code from the VTM, VMP, AMP, VMPP and AMPP concept classes
|
|
0 … 1 |
prsb03-dataelement-13660 link
|
|
Amount of vaccine administered.Free text |
|
1 … 1 Mandatory |
prsb03-dataelement-12472 link
|
|
The status of any change made to the medication. MUST CONTAIN STOPPED.FHIR value set: - Medication status
|
|
0 … 1 |
prsb03-dataelement-10579 link
|
|
The clinical indication for any changes in medication status
SNOMED CT:- ^1127601000000107 | Healthcare matters simple reference set (foundation
metadata concept) |
|
|
0 … 1 |
prsb03-dataelement-10580 link
|
|
The date of the discontinuationDate and time |
|
0 … 1 |
prsb03-dataelement-10582 link
|
|
Any additional comment about the discontinuation or amendment.Free text |
 |
Information and advice given |
|
1 … 1 Mandatory |
prsb03-dataelement-315 link
|
|
Information and advice given |
 |
|
Information and advice given |
|
1 … 1 Mandatory |
prsb03-dataelement-10215 link
|
|
The oral or written information or advice given to the patient, carer, other authorised
representative, care professional or other third party. May include advice about actions
related to medicines or other ongoing care activities on an ‘information prescription'.
State here if there are concerns about the extent to which the patient and/or carer
understand the information provided about diagnosis, prognosis and treatment.
Free text
|
 |
Contact for further information |
|
1 … 1 Mandatory |
prsb03-dataelement-329 link
|
|
Contact for further information |
 |
 |
Contact for further information record entry |
|
0 … * |
prsb03-dataelement-10659 link
|
|
This is a Contact for further information record entry. There may be 1 to many record
entries under a section. Each record entry is made up of a number of elements or data
items.
|
 |
 |
|
Contact for further information |
|
1 … 1 Mandatory |
prsb03-dataelement-10229 link
|
|
The contact details of whom to contact for information regarding this attendance. The
contact details may be for an individual or team (for example a phone number for the
emergency department administrator).Free text
|
 |
Plan and requested actions |
|
1 … 1 Mandatory |
prsb03-dataelement-535 link
|
|
The details of planned investigations, procedures and treatment, and whether this
plan has been agreed with the person or their legitimate representative.
|
 |
 |
Plan and requested actions record entry |
|
0 … * |
prsb03-dataelement-10661 link
|
|
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.
|
|
0 … 1 |
prsb03-dataelement-10445 link
|
|
The date on which the plan and requested actions were prepared.Date and time |
|
0 … 1 |
prsb03-dataelement-12167 link
|
|
The professional who prepared the plan and requested actions. |
|
0 … 1 |
prsb03-dataelement-12168 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-12169 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
0 … 1 |
prsb03-dataelement-12170 link
|
|
The grade of the professional.Free text |
|
0 … 1 |
prsb03-dataelement-12171 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-12172 link
|
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-12173 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-12174 link
|
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
0 … 1 |
prsb03-dataelement-10842 link
|
|
The location where the plan and requested actions were prepared. |
|
0 … 1 |
prsb03-dataelement-13684 link
|
|
The coded value for locationNHS data dictionary : - Organisation data service
|
|
0 … 1 |
prsb03-dataelement-13685 link
|
|
Free text field to be used if no code is availableFree text |
 |
 |
|
Actions for professionals |
|
1 … 1 Mandatory |
prsb03-dataelement-10436 link
|
|
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
|
 |
 |
|
Actions for person or their carer |
|
1 … 1 Mandatory |
prsb03-dataelement-10437 link
|
|
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
|
 |
 |
|
Agreed with the person or their legitimate representative |
|
0 … 1 |
prsb03-dataelement-10438 link
|
|
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
|
 |
 |
|
Outcome of plan and requested actions |
|
0 … * |
prsb03-dataelement-10950 link
|
|
The details of the outcome of the plan and requested actions.Free text. |
|
0 … 1 |
prsb03-dataelement-12175 link
|
|
Details of the person completing the record. |
|
0 … 1 |
prsb03-dataelement-12176 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-12177 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-12178 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-12179 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-12180 link
|
|
The organisation the person completing the record works for.
NHS data dictionary : -
Organisation data service
|
|
0 … 1 |
prsb03-dataelement-12181 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-12182 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-12183 link
|
|
Contact details of the person completing the record.
NHS data dictionary : - UK telephone number
|
 |
Person completing record |
|
1 … 1 Mandatory |
prsb03-dataelement-12605 link
|
|
Details of the person completing the record. |
 |
|
Name |
|
1 … 1 Mandatory |
prsb03-dataelement-12606 link
|
|
The name of the person completing the record.Free text. |
 |
|
Role |
|
1 … 1 Mandatory |
prsb03-dataelement-12607 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
 |
|
Grade |
|
0 … 1 |
prsb03-dataelement-12608 link
|
|
The grade of the person completing the record.Free text. |
 |
|
Specialty |
|
0 … 1 |
prsb03-dataelement-12609 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
 |
 |
Organisation |
|
1 … 1 Mandatory |
prsb03-dataelement-12610 link
|
|
The organisation the person completing the record works for.
NHS data dictionary : -
Organisation data service
|
 |
|
Professional identifier |
|
0 … 1 |
prsb03-dataelement-12611 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
 |
|
Date completed |
|
1 … 1 Mandatory |
prsb03-dataelement-12612 link
|
|
The date and time the record was completed.Date and time. |
 |
|
Contact details |
|
0 … * |
prsb03-dataelement-12613 link
|
|
Contact details of the person completing the record.
NHS data dictionary : - UK telephone number
|
 |
Senior Reviewing Clinician |
|
1 … 1 Mandatory |
prsb03-dataelement-12614 link
|
|
Senior Reviewing Clinician |
 |
|
Name |
|
1 … 1 Mandatory |
prsb03-dataelement-12615 link
|
|
The name of the senior clinician responsible for reviewing the patient treatment and
discharge plan.The person name as held on the source system. Where possible this should be broken
down into its constituent parts (prefix, given name, family name, suffix).
|
 |
|
Role |
|
0 … 1 |
prsb03-dataelement-14279 link
|
|
The role the professional has in relation to the person.FHIR value set : - sdsjobrole
|
 |
Care and support plan |
|
0 … 1 |
prsb03-dataelement-508 link
|
|
This records the decisions reached during conversation between the individual and
health and care professional about future plans and also records progress.
|
 |
 |
Strengths |
|
0 … * |
prsb03-dataelement-10419 link
|
|
Any strengths and assets the person has relating to their goals and hopes about their
health and well-being.
|
|
0 … 1 |
prsb03-dataelement-14369 link
|
|
The coded value associated with the person's strengths. Could be derived from the
assessment of the person e.g. 300738008 |Able to participate in leisure activities
(finding)|
SNOMED CT : - 1127601000000107 | Healthcare matters simple reference set (foundation
metadata concept) |
|
|
0 … 1 |
prsb03-dataelement-14370 link
|
|
Any supplementary or personalised information that relates to the person's strengths.Free text |
 |
 |
Needs, concerns or problems |
|
0 … * |
prsb03-dataelement-10414 link
|
|
Details of the person needs, concerns or problems
|
|
0 … 1 |
prsb03-dataelement-14371 link
|
|
The coded value associated with the person's needs, concerns or problems.SNOMED CT : - ^1127581000000103 |Health issues simple reference set|
|
|
0 … 1 |
prsb03-dataelement-14372 link
|
|
Any supplementary or personalised information that relates to the person's needs,
concerns and problems.
|
Free text
|
|
0 … * |
prsb03-dataelement-10413 link
|
|
The overall goals, hopes, aims or targets that the person has. Including anything
that the person wants to achieve that relates to their future health and wellbeing.
Each goal may include a description of why it is important to the person. Goals may
also be ranked in order of importance or priority to the person.
|
|
|
0 … 1 |
prsb03-dataelement-14373 link
|
|
The coded value associated with the person's goals, aim's and hopes. e.g. 999002111000000103
|Occupational therapy goals simple reference set (foundation metadata concept)|SNOMED CT : - 413350009|Finding with explicit context|: 246090004|Associated finding|=300798006
|Able to participate in sporting activities (finding)|, 408729009|Finding context|=410518001|Goal|
|
|
0 … 1 |
prsb03-dataelement-14374 link
|
|
Any supplementary and personalised information relating to the person's goals, aims
and hopes.Free text
|
|
0 … 1 |
prsb03-dataelement-14399 link
|
|
Assessment of the person's motivations to achieve this goal, how important the goal
is to the person on a scale of 1-10.Numeric scale 1 - 10
|
|
0 … * |
prsb03-dataelement-10408 link
|
|
Actions or activities the person or others plan to take to achieve the person's goals
and the resources required to do this.
|
|
0 … * |
prsb03-dataelement-10675 link
|
|
What the action is and how it is to be carried out? |
|
0 … 1 |
prsb03-dataelement-14383 link
|
|
The coded value for the action.
SNOMED CT : - <<71388002 |Procedure| OR <<129125009 |Procedure with explicit context|
|
|
0 … 1 |
prsb03-dataelement-14384 link
|
|
Any supplementary and personalised information for the action.Free text |
|
0 … 1 |
prsb03-dataelement-10676 link
|
|
Name and role (e.g. person, carer, GP, OT, etc.) of the person, or a team, carrying
out the proposed action, and, if relevant where action should take place.
|
|
0 … 1 |
prsb03-dataelement-14393 link
|
|
The name of the professional or person carrying out the proposed action.Free text |
|
0 … 1 |
prsb03-dataelement-14394 link
|
|
The role of the person providing the service.FHIR values set : - sdsjobrole
|
|
0 … 1 |
prsb03-dataelement-14395 link
|
|
The name of the team.Free text |
|
0 … 1 |
prsb03-dataelement-14396 link
|
|
Contact details of the professional (e.g. telephone number, email address etc.).Free text |
|
0 … 1 |
prsb03-dataelement-10677 link
|
|
Planned date, time, or interval, as relevantDate and time |
|
0 … 1 |
prsb03-dataelement-10678 link
|
|
Suggested strategies for potential problems.Free text. |
|
0 … 1 |
prsb03-dataelement-10679 link
|
|
The status of the action or activity e.g. in progress, done, refused |
|
0 … 1 |
prsb03-dataelement-14385 link
|
|
The coded value for the person's activity statusSNOMED CT : - ^999000081000000105 | Care planning action context values simple reference
set (foundation metadata concept) |
|
|
0 … 1 |
prsb03-dataelement-14386 link
|
|
Any supplementary or personalised information for the person's activity statusFree text |
|
0 … 1 |
prsb03-dataelement-10680 link
|
|
How confident the person feels to carry out the action associated to the goal.Numeric score 1 - 10 |
|
0 … 1 |
prsb03-dataelement-10682 link
|
|
Date when action/activity record was last updatedDate and time |
|
0 … 1 |
prsb03-dataelement-10683 link
|
|
When the action evaluation needs to be reviewed. SNOMED CT tag : - 425268008 | Review
of care plan (procedure) |Date and time.
|
|
0 … * |
prsb03-dataelement-10674 link
|
|
Details of the person's stage goals |
|
0 … 1 |
prsb03-dataelement-14284 link
|
|
A specific sub-goal that is related to the overall goal as agreed by the person in
collaboration with a professional.
|
|
0 … 1 |
prsb03-dataelement-14375 link
|
|
The coded expression associated with the person's stage goal.SNOMED CT : - 413350009|Finding with explicit context|: 246090004|Associated finding|=300798006
|Able to participate in sporting activities (finding)|, 408729009|Finding context|=410518001|Goal|
|
|
0 … 1 |
prsb03-dataelement-14376 link
|
|
Any supplementary or personalised information regarding the person's stage goal.Free text |
|
0 … 1 |
prsb03-dataelement-10681 link
|
|
The outcome of the stage goal
|
|
0 … 1 |
prsb03-dataelement-14378 link
|
|
The coded value for the person's stage goal outcome.SNOMED CT: - ^1127601000000107 |Healthcare matters simple reference set (foundation
metadata concept)|
|
|
0 … 1 |
prsb03-dataelement-14379 link
|
|
Any supplementary and personalised information relating to the person's outcome.Free text |
|
0 … 1 |
prsb03-dataelement-14377 link
|
|
The status associated with the person's stage goalSNOMED CT: - ^999000091000000107 | Care planning goal context values simple reference
set (foundation metadata concept) |
|
|
0 … * |
prsb03-dataelement-10416 link
|
|
Outcomes of each of the person’s goals, aims and targets. Includes comments recorded
by the person, date and status.
|
|
0 … 1 |
prsb03-dataelement-14380 link
|
|
The coded value associated with the person's overall goal outcomeSNOMED CT: - ^1127601000000107 |Healthcare matters simple reference set (foundation
metadata concept)|
|
|
0 … 1 |
prsb03-dataelement-14382 link
|
|
Any supplementary and personalised information relating to the person's goal outcome.
Free text
|
|
0 … 1 |
prsb03-dataelement-14400 link
|
|
The status associated with the person's overall goal.SNOMED CT: - ^999000091000000107 | Care planning goal context values simple reference
set (foundation metadata concept) |
|
 |
 |
Agreed with person or legitimate representative |
|
0 … 1 |
prsb03-dataelement-10409 link
|
|
Indicates whether the plan was discussed and agreed with the person or legitimate
representative.
|
 |
 |
|
Person or legitimate representative |
|
0 … 1 |
prsb03-dataelement-14322 link
|
|
Indicates whether the plan was discussed and agreed with the person or legitimate
representativePerson or legitimate representative
|
|
0 … 1 |
prsb03-dataelement-14323 link
|
|
The full name of the person in text representation.NHS data dictionary :- Person full name
|
|
0 … 1 |
prsb03-dataelement-14324 link
|
|
The role the professional has in relation to the person.FHIR value set : - sdsjobrole
|
 |
 |
Care funding source |
|
0 … 1 |
prsb03-dataelement-10410 link
|
|
A reference to the funding source and any conditions or limitations associated. |
|
0 … 1 |
prsb03-dataelement-14391 link
|
|
The organisation code of the care funding sourceNHS data dictionary : - organisation data service
|
|
0 … 1 |
prsb03-dataelement-14392 link
|
|
Any further information for the person's care funding source e.g. self fundedFree text |
 |
|
Date this plan was last updated |
|
0 … 1 |
prsb03-dataelement-10412 link
|
|
This is a record of the date that this care and support plan was last updated.Date and time |
 |
|
Other care planning documents |
|
0 … * |
prsb03-dataelement-10415 link
|
|
Reference other care planning documents, including the type, location and date.
This may include condition-specific plans, advance care plans, end of life care plan,
etc.Free text.
|
 |
|
Planned review date/interval |
|
0 … 1 |
prsb03-dataelement-10417 link
|
|
This is the date/interval when this information will next be reviewed. SNOMED CT tag
: - 425268008 | Review of care plan (procedure) |Date and time
|
 |
 |
Responsibility for review |
|
0 … 1 |
prsb03-dataelement-10418 link
|
|
This is a record of who has responsibility for arranging review of this information.
|
|
0 … 1 |
prsb03-dataelement-14345 link
|
|
The name of the professional with responsibility for the care of the person.Free text |
|
0 … 1 |
prsb03-dataelement-14346 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker, key worker, care home manager, care coordinator, LA
hospital liaison person, care home contact, hospital clinician, Independent Mental
Capacity Advocate (IMCA) etcFHIR value set : - SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-14347 link
|
|
Contact details of the professional (e.g. telephone number, email address etc.).Free text |
 |
 |
Location |
|
0 … 1 |
prsb03-dataelement-12044 link
|
|
The location where the care and support plan was prepared. |
|
0 … 1 |
prsb03-dataelement-13665 link
|
|
The coded value for locationNHS data dictionary: - Organisation data service
|
|
0 … 1 |
prsb03-dataelement-13666 link
|
|
Free text field to be used if no coded text available |
 |
 |
Performing professional |
|
0 … 1 |
prsb03-dataelement-12027 link
|
|
The professional who prepared the care and support plan. |
|
0 … 1 |
prsb03-dataelement-12028 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-12029 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
0 … 1 |
prsb03-dataelement-12030 link
|
|
The grade of the professional.Free text |
|
0 … 1 |
prsb03-dataelement-12031 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-12032 link
|
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-12033 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-12034 link
|
|
Contact details of the professionalNHS data dictionary - UK phone number
|
 |
 |
Person completing record |
|
0 … * |
prsb03-dataelement-12035 link
|
|
Details of the person completing the record. |
|
0 … 1 |
prsb03-dataelement-12036 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-12037 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-12038 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-12039 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-12040 link
|
|
The organisation the person completing the record works for.
NHS data dictionary : -
Organisation data service
|
|
0 … 1 |
prsb03-dataelement-12041 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-12042 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-12043 link
|
|
Contact details of the person completing the record.
NHS data dictionary : - UK telephone number
|
 |
Contingency/safety plans |
|
0 … * |
prsb03-dataelement-469 link
|
|
These are the things to do and people to contact, should an individual’s
health or other circumstances get worse for safety.
|
 |
 |
Trigger factors |
|
1 … * Mandatory |
prsb03-dataelement-10375 link
|
|
Signs to watch out for that may indicate a significant change in health or other circumstances
e.g. feeling agitated
|
|
0 … 1 |
prsb03-dataelement-14389 link
|
|
The trigger that leads to instigation of a significant change in health or other circumstances.
SNOMED CT: - ^1127581000000103 | Health issues simple reference set (foundation metadata
concept) |
|
|
0 … 1 |
prsb03-dataelement-14390 link
|
|
Any free text associated with the person's trigger factorFree text |
 |
 |
Contingency plan name |
|
0 … 1 |
prsb03-dataelement-10371 link
|
|
When the action evaluation needs to be reviewed. |
|
0 … 1 |
prsb03-dataelement-14387 link
|
|
The coded value for the type of care planSNOMED CT: - 999001471000000108 | Care plan type simple reference set (foundation
metadata concept) |
|
|
0 … 1 |
prsb03-dataelement-14388 link
|
|
Free text if no coded value is available.Free text |
 |
 |
What should happen |
|
0 … * |
prsb03-dataelement-10376 link
|
|
Guidance on specific actions or interventions that may be required or should be avoided
in specific situations. This may include circumstances where action needs to be taken
if a carer is unable to care for the person. A statement of suggested actions. Usually
expressed as: in the event of X do Y.
|
|
0 … 1 |
prsb03-dataelement-14403 link
|
|
The coded value for what should happen
SNOMED CT : - <<71388002 |Procedure| OR <<129125009 |Procedure with explicit context|
|
|
0 … 1 |
prsb03-dataelement-14404 link
|
|
Any supplementary or personalised information regarding what should happen
Free text
|
 |
 |
Who should be contacted |
|
0 … * |
prsb03-dataelement-10377 link
|
|
Who should be contacted in the event of significant problems or deterioration in health
or wellbeing. e.g. name, role and contact details.
|
|
0 … 1 |
prsb03-dataelement-14405 link
|
|
The name of the professional with responsibility for the care of the person.Free text |
|
0 … 1 |
prsb03-dataelement-14406 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker, key worker, care home manager, care coordinator, LA
hospital liaison person, care home contact, hospital clinician, Independent Mental
Capacity Advocate (IMCA) etcFHIR value set : - SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-14407 link
|
|
Contact details of the personal contact (e.g. telephone number, email address etc.)Free Text |
 |
 |
Agreed with person or legitimate representative |
|
0 … 1 |
prsb03-dataelement-10369 link
|
|
Indicates whether the plan was discussed and agreed with the person or legitimate
representative.
|
 |
 |
|
Person or legitimate representative |
|
0 … 1 |
prsb03-dataelement-14339 link
|
|
Indicates whether the plan was discussed and agreed with the person or legitimate
representativePerson or legitimate representative
|
|
0 … 1 |
prsb03-dataelement-14340 link
|
|
The full name of the person in text representation.NHS data dictionary :- Person full name
|
|
0 … 1 |
prsb03-dataelement-14341 link
|
|
The role the professional has in relation to the person.FHIR value set : - sdsjobrole
|
 |
|
Date this plan was last updated |
|
0 … 1 |
prsb03-dataelement-10372 link
|
|
The date that this contingency plan was last updated.Date and time |
 |
|
Planned review date/interval |
|
0 … 1 |
prsb03-dataelement-10373 link
|
|
This is the date/interval when this contingency plan will next be reviewed. SNOMED
CT tag : - 425268008 | Review of care plan (procedure) |Date and time
|
 |
 |
Responsibility for review |
|
0 … 1 |
prsb03-dataelement-10374 link
|
|
This is who has responsibility for arranging review of this information.
|
|
0 … 1 |
prsb03-dataelement-14342 link
|
|
The name of the professional with responsibility for the care of the person.Free text |
|
0 … 1 |
prsb03-dataelement-14343 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker, key worker, care home manager, care coordinator, LA
hospital liaison person, care home contact, hospital clinician, Independent Mental
Capacity Advocate (IMCA) etcFHIR value set : - SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-14344 link
|
|
Contact details of the professional (e.g. telephone number, email address etc.).Free text |
 |
 |
Coping strategies |
|
0 … * |
prsb03-dataelement-13850 link
|
|
Details of coping strategies used |
|
0 … 1 |
prsb03-dataelement-13851 link
|
|
The coping strategies are defined as thoughts and behaviours that people use to manage
the internal and external demands of situations that are appraised as stressful. This
should also include a record of any tools used to carry out the coping strategy.Free text
|
|
0 … 1 |
prsb03-dataelement-13852 link
|
|
The date when the coping strategy startedDate and time |
|
0 … 1 |
prsb03-dataelement-13853 link
|
|
The date when the coping strategy endedDate and time |
 |
 |
Relapse indicators / early warning signs |
|
0 … * |
prsb03-dataelement-13854 link
|
|
Details of the relapse indicators for the person. These may also be called 'early
warning signs'
|
|
0 … 1 |
prsb03-dataelement-14401 link
|
|
The coded value for relapse indicators/early warning signsSNOMED CT : - ^1127601000000107 | Healthcare matters simple reference set (foundation
metadata concept) |
|
|
0 … 1 |
prsb03-dataelement-14402 link
|
|
Any supplementary or personalised information regarding the relapse indicators/early
warning signsFree text
|
 |
 |
Advance statement |
|
0 … 1 |
prsb03-dataelement-10777 link
|
|
Written requests and preferences made by a person with capacity conveying their wishes,
beliefs and values for their future care should they lose capacity.
|
|
0 … 1 |
prsb03-dataelement-12267 link
|
|
The date when the advanced statements was made.Date and time |
|
0 … 1 |
prsb03-dataelement-12268 link
|
|
The location where the advanced statement was made. |
|
0 … 1 |
prsb03-dataelement-13698 link
|
|
The coded value for locationNHS data dictionary: - Organisation data service
|
|
0 … 1 |
prsb03-dataelement-13699 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-13695 link
|
|
Does the person have an advance statement. |
|
0 … 1 |
prsb03-dataelement-13696 link
|
|
The coded value for advance statementSNOMED CT: - 816281000000101 | Has advance statement (Mental Capacity Act 2005) (finding)
|
|
|
0 … 1 |
prsb03-dataelement-13697 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-13760 link
|
|
The location of where the advanced statement is held.Free text or URL |
|
0 … 1 |
prsb03-dataelement-12269 link
|
|
The professional who made the advance statement. |
|
0 … 1 |
prsb03-dataelement-12270 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-12271 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
0 … 1 |
prsb03-dataelement-12272 link
|
|
The grade of the professional.Free text |
|
0 … 1 |
prsb03-dataelement-12273 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-12274 link
|
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-12275 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-12276 link
|
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
0 … 1 |
prsb03-dataelement-12277 link
|
|
Details of the person completing the record. |
|
0 … 1 |
prsb03-dataelement-12278 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-12279 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-12280 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-12281 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-12282 link
|
|
The organisation the person completing the record works for.
NHS data dictionary : -
Organisation data service
|
|
0 … 1 |
prsb03-dataelement-12283 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-12284 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-12285 link
|
|
Contact details of the person completing the record.
NHS data dictionary : - UK telephone number
|
 |
|
Anticipatory medicines/equipment |
|
0 … * |
prsb03-dataelement-10370 link
|
|
Medicines or equipment available that may be required in specific situations and their
location. A statement regarding the availability or location of the anticipatory medicines/equipment.
SNOMED CT Tag : - 871021000000106 | Prescription of palliative care anticipatory medication
(procedure) |Free text
|
 |
 |
Location |
|
0 … * |
prsb03-dataelement-12079 link
|
|
The location where the contingency plan was prepared. |
|
0 … 1 |
prsb03-dataelement-13667 link
|
|
The coded value for locationNHS data dictionary : - Organisation data service
|
|
0 … 1 |
prsb03-dataelement-13668 link
|
|
Free text field to be used if no code is availableFree text |
 |
 |
Performing professional |
|
0 … 1 |
prsb03-dataelement-12045 link
|
|
The professional who prepared the contingency plans. |
|
0 … 1 |
prsb03-dataelement-12046 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-12047 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
0 … 1 |
prsb03-dataelement-12048 link
|
|
The grade of the professional.Free text |
|
0 … 1 |
prsb03-dataelement-12049 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-12050 link
|
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-12051 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-12052 link
|
|
Contact details of the professionalNHS data dictionary - UK phone number
|
 |
 |
Person completing record |
|
0 … 1 |
prsb03-dataelement-12053 link
|
|
Details of the person completing the record. |
|
0 … 1 |
prsb03-dataelement-12054 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-12055 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-12056 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-12057 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-12058 link
|
|
The organisation the person completing the record works for.
NHS data dictionary : -
Organisation data service
|
|
0 … 1 |
prsb03-dataelement-12059 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-12060 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-12061 link
|
|
Contact details of the person completing the record.
NHS data dictionary : - UK telephone number
|
 |
Additional support plans |
|
0 … * |
prsb03-dataelement-502 link
|
|
Additional support plans |
 |
 |
Additional support plan name |
|
0 … 1 |
prsb03-dataelement-10402 link
|
|
The name of the particular additional supporting plan, e.g. dieticians plan, wound
management plan, discharge management plan and behaviour support plan.
|
|
0 … 1 |
prsb03-dataelement-14397 link
|
|
The coded value for the type of care planSNOMED CT: - 999001471000000108 | Care plan type simple reference set (foundation
metadata concept) |
|
|
0 … 1 |
prsb03-dataelement-14398 link
|
|
Free text if no coded value is availableFree text |
 |
|
Additional support plan content |
|
0 … 1 |
prsb03-dataelement-10403 link
|
|
This is the content of any additional care and support plan which the person and/or
care professional consider should be shared with others providing care and support.
May be structured in different ways, e.g. tables, diagrams, images. This is the content
of any additional care and support plan which the individual and/or care professional
consider should be shared with others providing care and support. It should be structured
as recommended for the care and support plan and if contains additional detail, it
may be referenced here.Free text
|
 |
|
Planned review date/interval |
|
0 … 1 |
prsb03-dataelement-10405 link
|
|
This is the date/interval when this information will next be reviewed. SNOMED CT tag
: - 425268008 | Review of care plan (procedure) |Date and time
|
 |
 |
Responsibility for review |
|
0 … 1 |
prsb03-dataelement-10406 link
|
|
This is a record of who has responsibility for arranging review of this information.
Should include their name, role and contact details.
|
|
0 … 1 |
prsb03-dataelement-14348 link
|
|
The name of the professional with responsibility for the care of the person.Free text |
|
0 … 1 |
prsb03-dataelement-14349 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker, key worker, care home manager, care coordinator, LA
hospital liaison person, care home contact, hospital clinician, Independent Mental
Capacity Advocate (IMCA) etcFHIR value set : - SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-14350 link
|
|
Contact details of the professional (e.g. telephone number, email address etc.).Free text |
 |
|
Date this plan was last updated |
|
0 … 1 |
prsb03-dataelement-10407 link
|
|
This is a record of the date that this information was last updated.Date and time |
 |
 |
Location |
|
0 … 1 |
prsb03-dataelement-12080 link
|
|
The location where the additional support plan was prepared.ODS code or free text |
|
0 … 1 |
prsb03-dataelement-13722 link
|
|
The coded value for locationNHS data dictionary:- Organisation data service
|
|
0 … 1 |
prsb03-dataelement-13723 link
|
|
Free text field to be used if no code is availableFree text |
 |
 |
Performing professional |
|
0 … 1 |
prsb03-dataelement-12062 link
|
|
The professional who prepared the additional support plan. |
|
0 … 1 |
prsb03-dataelement-12063 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-12064 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
0 … 1 |
prsb03-dataelement-12065 link
|
|
The grade of the professional.Free text |
|
0 … 1 |
prsb03-dataelement-12066 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-12067 link
|
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-12068 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-12069 link
|
|
Contact details of the professionalNHS data dictionary - UK phone number
|
 |
 |
Person completing record |
|
0 … 1 |
prsb03-dataelement-12070 link
|
|
Details of the person completing the record. |
|
0 … 1 |
prsb03-dataelement-12071 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-12072 link
|
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
0 … 1 |
prsb03-dataelement-12073 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-12074 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-12075 link
|
|
The organisation the person completing the record works for.
NHS data dictionary : -
Organisation data service
|
|
0 … 1 |
prsb03-dataelement-12076 link
|
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
0 … 1 |
prsb03-dataelement-12077 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-12078 link
|
|
Contact details of the person completing the record.
NHS data dictionary : - UK telephone number
|