| Concept |
Card/Conf |
Id |
 |
Person demographics |
|
1 … 1 Mandatory |
prsb03-dataelement-10868 link |
|
The person's details and contact information. |
 |
|
Person name |
|
1 … 1 Mandatory |
prsb03-dataelement-10869 link |
|
Details of the person's name |
|
|
1 … * Mandatory |
prsb03-dataelement-13799 link |
|
The first name(s) of the person. This includes middle names.NHS data dictionary :- Person given name
|
|
|
1 … * Mandatory |
prsb03-dataelement-13800 link |
|
The family name or surname of the personNHS data dictionary : - Person family name
|
|
|
0 … 1 |
prsb03-dataelement-10870 link |
|
The name by which a person wishes to be addressed. The preferred name volunteered
by the person or a preferred name given by PDS that the person has asked to be called
by.NHS data dictionary: - Person full name
|
|
|
0 … 1 |
prsb03-dataelement-13089 link |
|
Person's titleNHS data dictionary: - Person title
|
|
|
0 … * |
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.
|
|
|
1 … 1 Mandatory |
prsb03-dataelement-13082 link |
|
Person's first line of address.
NHS data dictionary :- Address line 1
|
|
|
0 … 1 |
prsb03-dataelement-13083 link |
|
Person's second line of address.
NHS data dictionary :- Address line 2
|
|
|
0 … 1 |
prsb03-dataelement-13084 link |
|
Person's third line of address.
NHS data dictionary : - Address line 3
|
|
|
0 … 1 |
prsb03-dataelement-13085 link |
|
Person's fourth line of address.
NHS data dictionary : - Address line 4
|
|
|
0 … 1 |
prsb03-dataelement-13086 link |
|
Person's fifth line of address.NHS data dictionary : - Address line 5
|
|
|
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
|
|
|
Photograph |
|
0 … 1 |
prsb03-dataelement-13065 link |
|
A photograph of the person for identification and to show what the person looks like
normally.Mulitmedia file
|
|
|
Place of birth |
|
0 … 1 |
prsb03-dataelement-10884 link |
|
The country of birth of the person.NHS data dictionary :- Country code (birth)
|
|
|
Marital status |
|
0 … 1 |
prsb03-dataelement-10885 link |
|
An indicator to identify the legal marital status of the person.NHS data dictionary :- Person marital status
|
|
|
Immigration status |
|
0 … 1 |
prsb03-dataelement-13293 link |
|
Include details of the immigration status of the person, their permissions to live
and receive care and support in the UK e.g. asylum seeker, indefinite leave to remain
in the UK. Include start date, end date and any comments.
|
|
|
0 … 1 |
prsb03-dataelement-13304 link |
|
Details of the immigration status of the person, their permissions to live and receive
care and support in the UK e.g. asylum seeker, indefinite leave to remain in the UK.Code :- 1: Asylum Seeker; 2: Exceptional leave to remain in UK; 3: Indefinite Leave
to Remain in UK ;4: Limited Leave to Remain in UK; 5: No Recourse to Public Funds
(NRPF); 6: Other Nationals; 7: Refugee; 8: Unaccompanied Asylum Seeker; 9 EU pre-settled
status; 10: EU settled status
|
|
|
0 … 1 |
prsb03-dataelement-13294 link |
|
Start date of immigration statusDate and time |
|
|
0 … 1 |
prsb03-dataelement-13295 link |
|
End date of immigration statusDate and time |
|
|
0 … 1 |
prsb03-dataelement-13296 link |
|
Relevant comments about the person's immigration statusFree text |
|
|
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
|
|
|
Overseas visitor status |
|
0 … 1 |
prsb03-dataelement-10908 link |
|
The charging category relating to an overseas visitor.NHS data dictionary :- Overseas visitor charging catergory
|
|
GP practice |
|
0 … 1 |
prsb03-dataelement-101 link |
|
Details of the person's GP practice. |
|
|
GP practice record entry |
|
0 … 1 |
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
|
|
|
0 … 1 |
prsb03-dataelement-10001 link |
|
The identifier of the registered GP practice.
NHS data dictionary : - General medical practice code (patient registration)
|
|
|
0 … 1 |
prsb03-dataelement-10004 link |
|
Indication that the person has opted out of registering with a GP.SNOMED CT : - 1092961000000104 |Does not wish to register with an NHS general practitioner
(finding)| OR 1092941000000100 |Family using private general practitioner (finding)|
|
|
Individual requirements |
|
0 … 1 |
prsb03-dataelement-160 link |
|
The individual requirements of the person. |
|
|
Reasonable adjustment |
|
0 … 1 |
prsb03-dataelement-12991 link |
|
A record of reasonable adjustments that must be provided by the service to comply
with the Equality Act 2010.
|
|
|
|
Reasonable adjustment record entry |
|
0 … 1 |
prsb03-dataelement-13061 link |
|
This is a reasonable adjustment record entry. There may be 0 to many record entries
under a section. Each record entry is made up of a number of elements or data items
|
|
|
0 … 1 |
prsb03-dataelement-13098 link |
|
The location where the reasonable adjustment was identified. |
|
|
0 … 1 |
prsb03-dataelement-13357 link |
|
The coded value for location.NHS Data dictionary : - Organisation data service code
|
|
|
0 … 1 |
prsb03-dataelement-13358 link |
|
Free text field to be used if no code is availableFree text |
|
|
|
|
Reasonable adjustment flag |
|
0 … 1 |
prsb03-dataelement-13874 link |
|
Under the Equality Act 2010, organisations have a legal duty to make changes in their approach or provision to
ensure that services are as accessible to people with disabilities as they are for
everybody else. These changes are called reasonable adjustments.
Reasonable adjustments can mean alterations to buildings by providing lifts, wide
doors, ramps and tactile signage, but may also mean changes to policies, procedures
and staff training to ensure that services work equally well for people with physical
or sensory disabilities, learning disabilities or long-term conditions such as dementia.
Other adjustments include longer appointments, providing easy read materials or communications
via a carer. This legal duty is anticipatory which means a service should know about
a person’s need for adjustments when they are referred or present for care. For this
to happen, and for optimum care to be delivered, adjustments need to be recorded and
shared across the NHS.
SNOMED CT: - 1108111000000107 |Requires reasonable adjustments for health and care
access (Equality Act 2010) (finding)|
|
|
|
0 … 1 |
prsb03-dataelement-13017 link |
|
The reasonable adjustment required e.g. requires specific contact method, requires
communication professional
|
|
|
0 … 1 |
prsb03-dataelement-13505 link |
|
The coded value for reasonable adjustmentSNOMED CT : - Accessible information standard^999002121000000109 |Accessible information
- communication support simple reference set (foundation metadata concept)|^999002151000000104
|Accessible information - requires communication professional simple reference set
(foundation metadata concept)|^999002131000000106 |Accessible information - requires
specific contact method simple reference set (foundation metadata concept)|^999002141000000102
|Accessible information - requires specific information format simple reference set
(foundation metadata concept)|Refsets for other categories in development
|
|
|
0 … 1 |
prsb03-dataelement-13506 link |
|
Free text field to be used if no code is availableFree text |
|
|
|
|
Reasonable adjustment additional detail |
|
0 … 1 |
prsb03-dataelement-13018 link |
|
Further detail about the support required and the consequence of not providing it.Free text |
|
|
0 … 1 |
prsb03-dataelement-13020 link |
|
The date the reasonable adjustment was identified.Date and time |
|
|
0 … 1 |
prsb03-dataelement-13027 link |
|
The professional who confirmed the need for the reasonable adjustment. |
|
|
0 … 1 |
prsb03-dataelement-13028 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-13029 link |
|
The role the professional has in relation to the person.FHIR value set : - sdsjobrole
|
|
|
0 … 1 |
prsb03-dataelement-13030 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-13031 link |
|
The specialty of the professional.NHS data dictionary - Main specialty code
|
|
|
0 … 1 |
prsb03-dataelement-13032 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-13033 link |
|
The name of the organisation the professional works for. |
|
|
0 … 1 |
prsb03-dataelement-13034 link |
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
|
0 … 1 |
prsb03-dataelement-13035 link |
|
A record of the details of the person that entered the reasonable adjustment and the
date on which it was entered.
|
|
|
0 … 1 |
prsb03-dataelement-13036 link |
|
The name of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-13037 link |
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
|
0 … 1 |
prsb03-dataelement-13038 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-13039 link |
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-13040 link |
|
The organisation the person completing the record works for.
NHS data dictionary : -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-13041 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-13042 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-13043 link |
|
Contact details of the person completing the record.
NHS data dictionary : - UK telephone number
|
|
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 … 1 |
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 |
|
Consent |
|
0 … 1 |
prsb03-dataelement-10702 link |
|
Legal information captured relating to patient care, such as consent. |
|
|
Consent for information sharing |
|
0 … 1 |
prsb03-dataelement-10704 link |
|
This is a record of consent for information sharing under the common law duty of confidentiality.
Where consent has not been obtained or sought, the reason why should be provided.
Include best interests decision where person lacks capacity.Free text.
|
|
Referral details |
|
1 … 1 Mandatory |
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.
|
|
|
|
Person's input into service selection flag |
|
0 … 1 |
prsb03-dataelement-14934 link |
|
Flag to identify if the person has requested referral to a specific service. |
|
|
|
Person's input into service selection |
|
0 … * |
prsb03-dataelement-14935 link |
|
The person's requested service, the reason for rejection and comments. |
|
|
0 … 1 |
prsb03-dataelement-14941 link |
|
The service of where the referral is sent to. |
|
|
0 … 1 |
prsb03-dataelement-14942 link |
|
The coded value for serviceSNOMED CT: - 1127531000000102 |Services simple reference set (foundation metadata
concept)|
|
|
|
0 … 1 |
prsb03-dataelement-14943 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-14937 link |
|
The person's reason for rejecting suggested service. |
|
|
0 … 1 |
prsb03-dataelement-14938 link |
|
The referrer's comments on the person's input into service selection. |
|
|
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 |
|
|
1 … 1 Mandatory |
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 |
|
|
|
Person Referral Reference |
|
0 … 1 |
prsb03-dataelement-14946 link |
|
Human readable ID a patient can take from one service to another to identify one particular
referral – This is a marker with detail TBD
|
|
|
0 … 1 |
prsb03-dataelement-14933 link |
|
Marker for future ID to track multiple referrals, details TBD
|
|
|
0 … 1 |
prsb03-dataelement-12967 link |
|
An indication of the type of referral (e.g. 'Hospital Discharge Notification to Social
Care', 'GP Referral', etc.)
|
|
|
0 … 1 |
prsb03-dataelement-10007 link |
|
The method in which a referral is sent and received. This may be a letter, email,
transcript of a telephone conversation, Choose and Book, in person (self-referral)
etc.Allow National Codes only
Fax
Phone
Secure Messaging
Secure Email
Letter
NHS E-Referral Service
Self referral
|
|
|
0 … 1 |
prsb03-dataelement-10011 link |
|
The reason for the referral, e.g. diagnosis, treatment, transfer of care due to relocation,
investigation, second opinion, management of the patient (e.g. palliative care), or
carer's concerns.Free text
|
|
|
0 … 1 |
prsb03-dataelement-13455 link |
|
The coded value for reason for referralSNOMED CT :- ^1127581000000103 |Health issues simple reference set| |
|
|
0 … 1 |
prsb03-dataelement-13456 link |
|
Free text field to be used if no code is availableFree text |
|
|
|
Clinical urgency of referral |
|
0 … 1 |
prsb03-dataelement-10010 link |
|
The details of the clinical urgency of referral |
|
|
0 … 1 |
prsb03-dataelement-13835 link |
|
This is the priority of a request for servicesNHS data dictionary : - PRIORITY TYPE
|
|
|
|
|
Reason for urgency of referral |
|
0 … 1 |
prsb03-dataelement-10976 link |
|
The reason for urgency of referral if not routine.Free text |
|
|
1 … 1 Mandatory |
prsb03-dataelement-10008 link |
|
Details of where the referral is to be sent.
If not an individual, this could be a service, e.g. GP surgery, department, specialty,
subspecialty, educational institution, mental health etc.
|
|
|
0 … 1 |
prsb03-dataelement-10977 link |
|
Name of person the referral is to be sent to.Free text |
|
|
0 … 1 |
prsb03-dataelement-10978 link |
|
Role of person where the referral is to be sent to.FHIR value set : - sdsjobrole
|
|
|
0 … 1 |
prsb03-dataelement-10979 link |
|
The grade of the person where the referral is sent to.Free text |
|
|
0 … 1 |
prsb03-dataelement-10982 link |
|
The team or department of the person where the referral is being sent toFree text. |
|
|
0 … 1 |
prsb03-dataelement-10983 link |
|
The specialty the referral is being sent to e.g. physiotherapy, oncology, mental health
etcNHS data dictionary - Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-12412 link |
|
The service of where the referral is sent to. |
|
|
0 … 1 |
prsb03-dataelement-13509 link |
|
The coded value for serviceSNOMED CT: - 1127531000000102 |Services simple reference set (foundation metadata
concept)|
|
|
|
0 … 1 |
prsb03-dataelement-13510 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-10980 link |
|
The organisation of where the referral is to be sent. |
|
|
0 … 1 |
prsb03-dataelement-13511 link |
|
The coded value for organisationNHS data dictionary :- Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-13512 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-10981 link |
|
The contact details of where the referral is to be sent.Free text. |
|
|
0 … 1 |
prsb03-dataelement-10014 link |
|
Records whether specific criteria required for referral, to a particular service,
have been met (may be nationally or locally determined). This field is used to outline
which criteria have been met where a service has indicated specific criteria and to
explain the rationale for referral where criteria have not been met.Free text
|
|
|
0 … 1 |
prsb03-dataelement-10015 link |
|
Name of professional to be communicated with, if not the referrerFree text. |
|
Caller Details |
|
0 … 1 |
prsb03-dataelement-14927 link |
|
The details of the caller |
|
|
Person full name |
|
0 … 1 |
prsb03-dataelement-14928 link |
|
The full name of the person in text representation.NHS data dictionary :- Person full name
|
|
|
Relationship |
|
0 … 1 |
prsb03-dataelement-14929 link |
|
The relationship the personal contact has to the person, e.g. father, grandmother,
family friend etc.FHIR value set : - Related person
|
|
|
Person's telephone number |
|
0 … 1 |
prsb03-dataelement-14930 link |
|
The person's telephone numberNHS data dictionary : - UK telephone number
|
|
|
Preferred contact method |
|
0 … 1 |
prsb03-dataelement-14931 link |
|
Preferred contact method, e.g. email, letter, phone, text message etc.NHS data dictionary :- Communication contact method
|
|
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 |
|
|
Chief complaint |
|
1 … 1 Mandatory |
prsb03-dataelement-10905 link |
|
The nature of the person's chief complaint as assessed by the care professional first
assessing the person. Only ONE (chief complaint) sent as per the Chief Complaint code
set (SNOMED CT).
|
|
|
1 … 1 Mandatory |
prsb03-dataelement-14939 link |
|
The coded value of the chief complaintSNOMED CT |
|
|
0 … 1 |
prsb03-dataelement-14940 link |
|
Any free text if no coded value is availableFree text |
|
|
Person reported complaints or issues |
|
0 … 1 |
prsb03-dataelement-10906 link |
|
Person stated description of the health problems and issues. This may differ from
the clinicians impression. This may also be expressed on behalf of the person, eg
by parent or carer.Free text
|
|
|
Addtional information sources |
|
0 … 1 |
prsb03-dataelement-14932 link |
|
The source of additional relevant information about the person e.g. summary care record
or link via NRL or copy and paste local record e.g. Special Patient Notes (SPN)Free text or url
|
|
Clinical Summary |
|
0 … 1 |
prsb03-dataelement-247 link |
|
Clinical Summary |
|
|
Clinical narrative |
|
0 … 1 |
prsb03-dataelement-10150 link |
|
A description detailing a patient’s reason for attendance, results from the diagnostic
and treatment process.Free text
|
|
Social context |
|
0 … 1 |
prsb03-dataelement-136 link |
|
The social setting in which the person lives, such as their household, occupational
history, and lifestyle factors.
|
|
|
Services and care |
|
0 … 1 |
prsb03-dataelement-12482 link |
|
The description of services and care providing support for person's health and social
well-being.Free text. The record of the services and care as provided by the person or their
representative.
|
|
|
Household composition |
|
0 … 1 |
prsb03-dataelement-10036 link |
|
Details of the person's household composition. |
|
|
0 … 1 |
prsb03-dataelement-11770 link |
|
The date when the household composition was taken.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-13271 link |
|
The location where the household composition was taken. |
|
|
0 … 1 |
prsb03-dataelement-13272 link |
|
The coded value for location.NHS data dictionary : - Organisation data service code
|
|
|
0 … 1 |
prsb03-dataelement-13273 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-13261 link |
|
Description of the household composition e.g. lives alone, lives with family, lives
with partner, etc.
|
|
|
0 … 1 |
prsb03-dataelement-13262 link |
|
The coded value of household compositionSNOMED CT: - 1027891000000106 | Household composition findings simple reference set
(foundation metadata concept) |
|
|
|
0 … 1 |
prsb03-dataelement-13263 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-11648 link |
|
The professional who took the household composition. |
|
|
0 … 1 |
prsb03-dataelement-11649 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11650 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-11651 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-11652 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-11653 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-11654 link |
|
The name of the organisation the professional works for. |
|
|
0 … 1 |
prsb03-dataelement-11655 link |
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
|
0 … 1 |
prsb03-dataelement-11521 link |
|
Details of the person completing the record. |
|
|
0 … 1 |
prsb03-dataelement-11522 link |
|
The name of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11523 link |
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
|
0 … 1 |
prsb03-dataelement-11524 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11525 link |
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-11526 link |
|
The organisation the person completing the record works for.
NHS data dictionary : -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-11527 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-11528 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-11529 link |
|
Contact details of the person completing the record.
NHS data dictionary : - UK telephone number
|
|
|
Social circumstances |
|
0 … 1 |
prsb03-dataelement-10043 link |
|
Details of the persons social circumstances |
|
|
0 … 1 |
prsb03-dataelement-11824 link |
|
The date when the social circumstances were taken.Date and time |
|
|
0 … 1 |
prsb03-dataelement-11825 link |
|
The location where the social circumstances were taken. |
|
|
0 … 1 |
prsb03-dataelement-13339 link |
|
The coded value for the location |
|
|
0 … 1 |
prsb03-dataelement-13340 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-13341 link |
|
A person’s social background, network and personal circumstances, e.g. housing. This
should include whether the person is a carer.Free text
|
|
|
0 … 1 |
prsb03-dataelement-11826 link |
|
The professional who took the social circumstances. |
|
|
0 … 1 |
prsb03-dataelement-11827 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11828 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-11829 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-11830 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-11831 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-11832 link |
|
The name of the organisation the professional works for. |
|
|
0 … 1 |
prsb03-dataelement-11833 link |
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
|
0 … 1 |
prsb03-dataelement-11584 link |
|
Details of the person completing the record. |
|
|
0 … 1 |
prsb03-dataelement-11585 link |
|
The name of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11586 link |
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
|
0 … 1 |
prsb03-dataelement-11587 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11588 link |
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-11589 link |
|
The organisation the person completing the record works for.
NHS data dictionary : -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-11590 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-11591 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-11592 link |
|
Contact details of the person completing the record.
NHS data dictionary : - UK telephone number
|
|
|
Accommodation status |
|
0 … 1 |
prsb03-dataelement-10047 link |
|
Details of the type of accommodation where the person lives. |
|
|
0 … 1 |
prsb03-dataelement-11864 link |
|
The date when the accommodation status was taken.Date and time |
|
|
0 … 1 |
prsb03-dataelement-11865 link |
|
The location where the accommodation was taken. |
|
|
0 … 1 |
prsb03-dataelement-13352 link |
|
The coded value of locationNHS Data dictionary : - Organisation data service code
|
|
|
0 … 1 |
prsb03-dataelement-13353 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-13348 link |
|
An indication of the type of accommodation where the person lives.
This should be based on the main or permanent residence.
|
|
|
0 … 1 |
prsb03-dataelement-13349 link |
|
The coded value for accommodation statusNHS data dictionary :- Accommodation status
|
|
|
0 … 1 |
prsb03-dataelement-13350 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-11866 link |
|
The professional who took the accommodation status. |
|
|
0 … 1 |
prsb03-dataelement-11867 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11868 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-11869 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-11870 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-11871 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-11872 link |
|
The name of the organisation the professional works for. |
|
|
0 … 1 |
prsb03-dataelement-11873 link |
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
|
0 … 1 |
prsb03-dataelement-11874 link |
|
Details of the person completing the record. |
|
|
0 … 1 |
prsb03-dataelement-11875 link |
|
The name of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11876 link |
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
|
0 … 1 |
prsb03-dataelement-11877 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11878 link |
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-11879 link |
|
The organisation the person completing the record works for.
NHS data dictionary : -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-11880 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-11881 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-11882 link |
|
Contact details of the person completing the record.
NHS data dictionary : - UK telephone number
|
|
Allergies and adverse reactions |
|
0 … 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. |
|
|
0 … 1 |
prsb03-dataelement-13845 link |
|
The coded value for methodSNOMED CT : - ^999000041000001103 | ePrescribing method simple reference set (foundation
metadata concept) |
|
|
|
0 … 1 |
prsb03-dataelement-13846 link |
|
Free text field to be used if no coded text available |
|
|
|
|
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 |
|
0 … 1 |
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 |
|
|
0 … 1 |
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 |
|
Plan and requested actions |
|
0 … 1 |
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 |
|
0 … 1 |
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 |
|
0 … 1 |
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 and carer concerns expectations and wishes |
|
0 … * |
prsb03-dataelement-292 link |
|
Person and carer concerns, expectations and wishes |
|
|
Person and carer concerns, expectations and wishes |
|
0 … 1 |
prsb03-dataelement-10192 link |
|
Description of the concerns, wishes or goals of the person in relation to their care,
as expressed by the person, their representative or carer. Record who has expressed
these (patient or carer/ representative on behalf of the patient).Where the person
lacks capacity this may include their representative's concerns, expectations or wishes. Free Text
|
|
|
Person completing record |
|
0 … 1 |
prsb03-dataelement-13740 link |
|
A record of the details of the person that entered the impairment and the date on
which it was entered.
|
|
|
0 … 1 |
prsb03-dataelement-13741 link |
|
The name of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-13742 link |
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
|
0 … 1 |
prsb03-dataelement-13743 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-13744 link |
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-13745 link |
|
The organisation the person completing the record works for.
NHS data dictionary : -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-13746 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-13747 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-13748 link |
|
Contact details of the person completing the record.
NHS data dictionary : - UK telephone number
|
111 referral
111 referral
Response