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draft Transaction E-discharge summary 2.16.840.1.113883.3.1937.777.28.4.100

Data Set  2.16.840.1.113883.3.1937.777.28.1.1

Name Id
draft E-discharge summary (3.2) 2.16.840.1.113883.3.1937.777.28.4.100
Version / effective date Expiration date
2018‑10‑31
Description
E-discharge summary
Name Details [‑]
folder draft Person demographics 1 … 1 Mandatory
prsb03-dataelement-10868
Id prsb03-dataelement-10868 (2019‑03‑27 19:02:25)
Cardinality 1 … 1 Mandatory
Context The PDS (Personal Demographics Service) should be used as the source of this information. The mandatory information in this section is person’s name, date of birth and address. There can be multiple addresses associated with a person including temporary and correspondence addresses.on guidance.
Description The person's details and contact information.
target Used by one transaction, 0 templates, inherited once
 
folder draft Person name 1 … 1 Mandatory
prsb03-dataelement-10869
Id prsb03-dataelement-10869 (2019‑03‑27 19:05:18) 1
Cardinality 1 … 1 Mandatory
Description Details of the person's name
Relationship
target Used by one transaction, 0 templates, inherited once
 
draft Person first name 1 … * Mandatory
prsb03-dataelement-13799
Id prsb03-dataelement-13799 (2020‑11‑09 16:09:39)
Cardinality 1 … * Mandatory
Description The first name(s) of the person. This includes middle names.
Rationale Patient.name.given
Operationalization NHS data dictionary :- Person given name
Value Domain
Property
max length
35
target Used by one transaction, 0 templates, inherited once
 
draft Person family name 1 … * Mandatory
prsb03-dataelement-13800
Id prsb03-dataelement-13800 (2020‑11‑09 16:43:41)
Cardinality 1 … * Mandatory
Description The family name or surname of the person
Rationale Patient.name.family
Operationalization NHS data dictionary : - Person family name

Value Domain
Property
max length
35
target Used by one transaction, 0 templates, inherited once
 
draft Person preferred name 0 … 1
prsb03-dataelement-10870
Id prsb03-dataelement-10870 (2019‑03‑27 19:06:43)
Cardinality 0 … 1
Description 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.
Relationship
Rationale Patient.name
Operationalization NHS data dictionary: - Person full name
Value Domain
Property
max length
70
target Used by one transaction, 0 templates, inherited once
 
draft Title 0 … 1
prsb03-dataelement-13089
Id prsb03-dataelement-13089 (2020‑06‑04 17:22:32) 0.1
Cardinality 0 … 1
Description Person's title
Rationale Patient.name.prefix
Operationalization NHS data dictionary: - Person title
Value Domain
Property
max length
35
target Used by one transaction, 0 templates, inherited once
 
draft Person name suffix 0 … *
prsb03-dataelement-13798
Id prsb03-dataelement-13798 (2020‑11‑08 22:52:48)
Cardinality 0 … *
Description A textual suffix that may be added to the end of a PERSON's name, for example, OBE, MBE, BSc, JP, GM
Rationale Patient.name.suffix
Operationalization NHS data dictionary: - Person suffix
Value Domain
Property
max length
35
target Used by one transaction, 0 templates, inherited once
 
draft Person full name 0 … 1
prsb03-dataelement-13801
Id prsb03-dataelement-13801 (2020‑11‑09 17:03:29)
Cardinality 0 … 1
Description The full name of the person in text representation.
Rationale Patient.name.text
Operationalization NHS data dictionary :- Person full name
Value Domain
Property
max length
70
target Used by one transaction, 0 templates, inherited 6 times
 
draft Date of birth 1 … 1 Mandatory
prsb03-dataelement-10871
Id prsb03-dataelement-10871 (2019‑03‑27 19:08:01) 1
Cardinality 1 … 1 Mandatory
Description The date of birth of the person.

Properties

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

Properties

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

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

NHS_NSS: https://www.ndc.scot.nhs.uk/Dictionary-A-Z/Definitions/index.asp?Search=E&ID=243&Title=Ethnic%20Group
Operationalization NHS data dictionary :- Ethnic category
Value Domain
Property
max length
2
target Used by one transaction, 0 templates, inherited once
 
draft Religion 0 … 1
prsb03-dataelement-10876
Id prsb03-dataelement-10876 (2019‑03‑27 19:15:05) 1
Cardinality 0 … 1
Description The religious affiliation as specified by the person.
Relationship
Rationale Patient.extension(religiousAffiliation)
Source NHS NSS: - https://www.ndc.scot.nhs.uk/Dictionary-A-Z/Definitions/index.asp?Search=R&ID=795&Title=Religion
Operationalization
SNOMED_CT:- Religion

Value Domain
target Used by one transaction, 0 templates, inherited once
 
draft Sex 0 … 1
prsb03-dataelement-10877
Id prsb03-dataelement-10877 (2019‑03‑27 19:15:45) 1
Cardinality 0 … 1
notice There is an open issue with this item:
Description The person’s phenotypic sex. Determines how the person will be treated clinically.
Relationship
Operationalization NHS data dictionary: - person phenotypic sex
Value Domain
Property
max length
1
target Used by one transaction, 0 templates, inherited once
 
draft NHS number 0 … 1
prsb03-dataelement-10879
Id prsb03-dataelement-10879 (2019‑03‑27 19:16:57) 1
Cardinality 0 … 1
Context NHS number (or equivalent, e.g. CHI number in Scotland), is likely to be the primary identifier however existing national guidance should be followed, including how to handle patients without an NHS number, for example, overseas visitors. 
Description The unique identifier for a person within the NHS in England and Wales.

Properties

FHIR Patient.identifier.nhsnumber
Relationship
Rationale Patient.identifier(nhsnumber)
Operationalization NHS data dictionary:- NHS number
Value Domain
Property
max length
10
target Used by one transaction, 0 templates, inherited once
 
draft NHS number status indicator 0 … 1
prsb03-dataelement-13297
Id prsb03-dataelement-13297 (2020‑08‑06 12:08:33)
Cardinality 0 … 1
Description Provides an indication of the reliability of an NHS Number.
Rationale Patient.identifier(nhsnumber).extension(nhsverificationstatus)
Operationalization NHS data dictionary :- NHS number status indicator
Value Domain
Property
max length
2
target Used by one transaction, 0 templates, inherited once
 
draft Other identifier 0 … *
prsb03-dataelement-10880
Id prsb03-dataelement-10880 (2019‑03‑27 19:18:59)
Cardinality 0 … *
Description Country specific or local identifier, e.g. Community Health Index (CHI) in Scotland.
Relationship
Rationale Patient.identifier
Operationalization
Value Domain
Property
max length
20
target Used by one transaction, 0 templates, inherited once
 
folder draft Person's address 1 … * Mandatory
prsb03-dataelement-10881
Id prsb03-dataelement-10881 (2019‑03‑27 19:19:27)
Cardinality 1 … * Mandatory
Description Person’s usual place of residence, and where relevant temporary and correspondence addresses.

Properties

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

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

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

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

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

Value Domain
Property
max length
8
target Used by one transaction, 0 templates, inherited once
 
draft Address type 0 … 1
prsb03-dataelement-13221
Id prsb03-dataelement-13221 (2020‑07‑08 15:58:39)
Cardinality 0 … 1
Description The type of address e.g. Main address, Temp address
Rationale Patient.address.use
Operationalization NHS data dictionary : - Address association type
Value Domain
Property
max length
1
target Used by one transaction, 0 templates, inherited once
 
folder draft Person's contact details 0 … 1
prsb03-dataelement-13804
Id prsb03-dataelement-13804 (2020‑11‑25 18:32:36)
Cardinality 0 … 1
Description Details of the person's contact information.
target Used by one transaction, 0 templates, inherited once
 
draft Preferred contact method 0 … 1
prsb03-dataelement-10886
Id prsb03-dataelement-10886 (2019‑03‑27 19:29:17)
Cardinality 0 … 1
Description Preferred contact method, e.g. email, letter, phone, text message etc.
Relationship
Operationalization NHS data dictionary :- Communication contact method
Value Domain
Property
max length
1
target Used by one transaction, 0 templates, inherited 2 times
 
folder draft Person's telephone number details 0 … *
prsb03-dataelement-10883
Id prsb03-dataelement-10883 (2019‑03‑27 19:22:39)
Cardinality 0 … *
Description The person's telephone number details

Properties

FHIR Patient.telecom
Relationship
target Used by one transaction, 0 templates, inherited once
 
draft Person's telephone number 0 … 1
prsb03-dataelement-13808
Id prsb03-dataelement-13808 (2020‑11‑26 16:51:24)
Cardinality 0 … 1
Description The person's telephone number
Rationale Patient.contact.telecon.value
Operationalization NHS data dictionary : - UK telephone number
Value Domain
Property
max length
35
target Used by one transaction, 0 templates, inherited 2 times
 
draft Person's telephone number type 0 … 1
prsb03-dataelement-13805
Id prsb03-dataelement-13805 (2020‑11‑25 18:37:54)
Cardinality 0 … 1
Description The contact type e.g. home, mobile
Rationale Patient.telecon.use
Operationalization FHIR value set: - Contact point use
Value Domain
Property
max length
6
Example Home
Example Mobile
Example Temp
Example Old
Example Work
target Used by one transaction, 0 templates, inherited once
 
draft Preference of telephone number 0 … 1
prsb03-dataelement-13809
Id prsb03-dataelement-13809 (2020‑11‑26 16:55:09)
Cardinality 0 … 1
Description The preferred order of use for the telephone number
Rationale Patient.telecom.rank
Operationalization Preference of use 1-5, 1 being the highest.
Value Domain
target Used by one transaction, 0 templates, inherited once
 
folder draft Person's email address details 0 … *
prsb03-dataelement-13807
Id prsb03-dataelement-13807 (2020‑11‑26 16:29:22)
Cardinality 0 … *
Description Details of the person's email address
target Used by one transaction, 0 templates, inherited once
 
draft Person's email address 0 … 1
prsb03-dataelement-10882
Id prsb03-dataelement-10882 (2019‑03‑27 19:20:19)
Cardinality 0 … 1
Description Email address of the person.

Properties

FHIR Patient.telecom
Relationship
Rationale Patient.contact.telecon.value
Operationalization NHS data dictionary :- Contact email address
Value Domain
Property
max length
255
target Used by one transaction, 0 templates, inherited once
 
draft Person's email address type 0 … 1
prsb03-dataelement-13811
Id prsb03-dataelement-13811 (2020‑11‑26 17:30:54)
Cardinality 0 … 1
Description The type of email address, home, work
Rationale Patient.telecon.use
Operationalization FHIR value set: - Contact point use
Value Domain
Property
max length
6
Example Home
Example Work
Example old
target Used by one transaction, 0 templates, inherited once
 
draft Preference of email address 0 … 1
prsb03-dataelement-13810
Id prsb03-dataelement-13810 (2020‑11‑26 17:07:11)
Cardinality 0 … 1
Description The preferred order of use of email address
Rationale Patient.telecon.rank
Operationalization Preference of use 1-5, 1 being the highest.
Value Domain
target Used by one transaction, 0 templates, inherited once
 
draft Other contact information 0 … 1
prsb03-dataelement-13806
Id prsb03-dataelement-13806 (2020‑11‑26 16:07:06)
Cardinality 0 … 1
Description Contact details via fax, sms, url
Rationale Patient.contact.telecon.value
Operationalization NHS data dictionary:- Communication contact string
Value Domain
Property
max length
255
target Used by one transaction, 0 templates, inherited once
 
draft Organ and tissue donation 0 … 1
prsb03-dataelement-13847
Id prsb03-dataelement-13847 (2020‑12‑30 11:45:54)
Cardinality 0 … 1
Context To improve the accuracy of the organ and tissue donation element, systems should link directly to the organ donation register where possible.
Description Whether the person has opted out of automatic organ and/or tissue donation where applicable. This is information provided by the national register.
Operationalization Flag: - Yes or No
Value Domain
target Used by one transaction, 0 templates, inherited once
 
folder draft GP practice 1 … 1 Mandatory
prsb03-dataelement-101
Id prsb03-dataelement-101 (2018‑10‑31)
Cardinality 1 … 1 Mandatory
Description Details of the person's GP practice.
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft GP practice record entry 0 … *
prsb03-dataelement-10643
Id prsb03-dataelement-10643 (2018‑11‑09 14:59:24)
Cardinality 0 … *
Description This is an GP practice record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items
target Used by one transaction, 0 templates, inherited 0 times
 
draft GP name 0 … 1
prsb03-dataelement-10003
Id prsb03-dataelement-10003 (2018‑10‑31)
Cardinality 0 … 1
Description 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.

Properties

FHIR Practitioner.name, where PractitionerRole.code=GP
Rationale Practitioner.name
Operationalization Free text
Value Domain
Property
max length
70
target Used by one transaction, 0 templates, inherited 0 times
 
draft GP practice details 0 … 1
prsb03-dataelement-10002
Id prsb03-dataelement-10002 (2018‑10‑31)
Cardinality 0 … 1
Description 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.

Properties

FHIR PractitionerRole.organisation.Name (0..1) PractitionerRole.organisation.telcom (0..*) PractitionerRole.organisation.Address (0..*)
Rationale PractitionerRole.organisation.Name (0..1)

PractitionerRole.organisation.telcom (0..*)

PractitionerRole.organisation.Address (0..*)
Operationalization Free text
Value Domain
Property
max length
150
target Used by one transaction, 0 templates, inherited 0 times
 
draft GP practice identifier 1 … 1 Mandatory
prsb03-dataelement-10001
Id prsb03-dataelement-10001 (2018‑10‑31)
Cardinality 1 … 1 Mandatory
Description The identifier of the registered GP practice.

Properties

FHIR Sliced into ODS and local identifier. PratitionerRole.organisation.identifier
Rationale PratitionerRole.organisation.identifier
Operationalization
Value Domain
Property
max length
6
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft About me 0 … 1
prsb03-dataelement-466
Id prsb03-dataelement-466 (2018‑10‑31)
Cardinality 0 … 1
Context This section supports the sharing of information that the individual thinks is important to share with people caring for and supporting them. This should include information about what matters to the person (their needs, preferences, concerns and wishes). The About me section should be prominently displayed in a shared care record as it is important information about the person relevant to all care and support providers. It is an optional section in the eDischarge summary standard. 
A carer or clinical staff member should quickly review the About Me section before meeting and supporting the individual. This information may be available in multimedia formats e.g. jpeg, mp3 etc. These documents are likely to follow a variety of formats but should be transferred in their entirety.
Care will need to be taken in local implementations to differentiate between information in the About me section and things like Advance Directives and preferences and wishes expressed in other care plans such as end of life plans. Likewise reference to any other legal documentation e.g. lasting power of attorney in the About Me should be checked against the electronic record.  
Professionals using the information in the About Me section should be reminded that the information is entered by the individual from their perspective and therefore any clinical information contained in the About Me e.g. their allergies or their conditions could be compared with other information in the electronic record.
If there are discrepancies between the About Me information and the information in the electronic record, following discussion between the clinician and individual to reconcile the differences, both the individual and the clinician should (where appropriate) amend their records to align them.
As the About Me section allows for free text and multimedia information it is recommended the individual (or the person supporting them to write the information) is prompted to consider: 
•that the most important information comes first in any sub-category
•avoiding adding too much information as important information may be buried within text making it difficult for the professionals to easily digest the information and use it to personalise care 
•when multimedia is effective and ensure that videos are kept short
•that they do not need to put information about themselves in every element (sub-category of the About Me section) only where they feel they have information they want to share
The elements (sub-categories) enable the individual to record whatever is most important to them and therefore are broad and few in number. Local implementers could decide to structure the information within the sub-categories further but it is not mandatory.
To help individuals to structure their information within the sub-categories a set of possible prompt questions have been included with this guidance. They will not apply to all individuals and if implementers are designing a user interface for a particular population cohort they may wish to use a sub-set of the questions and consult guidance from relevant bodies (for example the National Autistic Society, Alzheimer’s Society, Dementia UK and Macmillan etc.) and tailor prompt questions accordingly.
The About Me information should sit alongside clinical and social care information entered by professionals in the shared care record such as medications and allergies. This would enable professionals to cross-check information given in the About Me section with other information in the record.  

What it is: 
  • a section within the core information standard and transfer of care standards which is designed for sharing information that the person (or somebody acting on their behalf) considers important to share about themselves with others caring for or supporting them for the purposes of direct care, to enable the best, personalised care and support to be provided
  • aimed at capturing an individual’s needs, preferences and wishes for how they receive care and support in a person-centred approach. It could also include information on the individual’s strengths to provide a basis for building upon personal and community assets to enable self-care where possible
  • aimed at capturing holistic information about the individual (not just what people caring for and supporting the individual need to know when someone is unwell (or in an emergency) but what they are able to do and enjoy on a typical day)
  • divided into sub-categories of information to help individuals to determine what information to share and to help those providing care and support to the individual to easily locate the information they need
  • designed to be generic and apply to everyone, from those who have complex care and support needs to those who rarely require care and/or support. This could include, for example, older people, people with mental health conditions, people with learning disabilities, people with physical impairments and people with long-term conditions etc.

What it is not: 

It is not:
  • intended to be used for determining an individual’s right to access social care or health services 
  • a person-held record, therefore, does not include any information recorded by professionals in an electronic patient record such as medications, problems, examination findings and investigation results. In a shared care record the About Me (information from the person themselves) would sit alongside clinical and social care information recorded by professionals about the person
  • a care or support plan. Individuals may have an end of life care plan, plans for management of specific conditions or situations (e.g. an asthma management plan or a behaviour support plan) and these would sit alongside the About Me information in a shared care record 
  • a go-to section for legal information such as Deprivation of Liberty Safeguards, Lasting Power of Attorney, Nearest relative or Next of Kin 
  • a prescriptive definition of what must be included. The About Me section enables an individual to reflect their unique position. They can include whatever information they choose in an About Me section and they can choose not to share any information at all 
  • a definition of who should be able to see the information in the About Me section for an individual (local implementers will need to determine this based on the legal framework and NHS England’s Information Governance Framework and Role-Based Access Control framework) 
  • a definition of how the information in the About Me section should be presented to professionals. What is presented and how much information (history) and how it is viewed and accessed should be defined locally 
  • a definition of a form or system for capturing information in the About Me section from an individual
  • a definition of how and where individuals can record information in the About Me section, how it is captured and displayed in clinical systems and shared records, how it is kept up-to-date and how multiple versions of information in the About Me section are managed (e.g. About Me records originating in different settings) 

Description About me
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft What is most important to me 0 … 1
prsb03-dataelement-12964
Id prsb03-dataelement-12964 (2020‑03‑30 10:50:29) 0.3
Cardinality 0 … 1
Description A description of what is most important to you.
Source SNOMED CT Tag : -  363882003 | Motivation (observable entity) |

target Used by one transaction, 0 templates, inherited 0 times
 
draft What is most important to me 0 … 1
prsb03-dataelement-14325
Id prsb03-dataelement-14325 (2021‑07‑01 13:49:23)
Cardinality 0 … 1
Context
A description of what is most important to you.

Emergency Information: Include any essential information that any professional in health and social care should know about you in any situation, including emergencies. 

Other information this could include:
  • Values
  • Spirituality and religion
  • Ethnicity
  • Culture
  • Pets
  • Goals and aspirations
  • Meaningful activities including leisure activities, visiting places, sport and exercise, listening to music, employment, education, volunteering 
Consider including any important preferences, needs and wishes that indicate how you need to be cared for and supported in an emergency such the need to avoid any disturbing stimuli e.g. noise, visual, smell, taste or touch etc. for example by being seen in a quiet or darkened room, the need for visual aids, the need for a translator or the need for vegan appropriate medications etc. Consider including any food allergies or risk of choking.

Consider referencing other documents in which you have already recorded any needs, wishes and preferences such as an Advance Decision, a lasting power of attorney, a communication or hospital passport or an end of life plan. 
Description A description of what is most important to you 
 Emergency Information : - Include any essential information that any professional in health and social care should know about the you in any situation, including emergencies.
Other Information : -This could include : - Values, Spirituality/religion, Ethnicity, Culture, Pets, Goals and aspirations, Meaningful activities including leisure activities, visiting places, sport and exercise, listening to music, employment, education, volunteering
Operationalization Free text
Value Domain
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft People who are important to me 0 … 1
prsb03-dataelement-13009
Id prsb03-dataelement-13009 (2020‑04‑27 11:23:17) 0.3
Cardinality 0 … 1
Description Details of who is important to you and why. 
Source SNOMED CT Tag: - 302160007 | Household, family and support network detail (observable entity) |

target Used by one transaction, 0 templates, inherited 0 times
 
draft People who are important to me 0 … 1
prsb03-dataelement-14327
Id prsb03-dataelement-14327 (2021‑07‑01 16:27:25)
Cardinality 0 … 1
Context
Details of who is important to you and why. They could be family members, carers, friends, members of staff etc.
  • Include how you want the people important to you to be engaged and involved in your care and support in both emergency and normal situations.
  • Include how you stay connected to the people important to you.
  • Who should not be contacted or consulted about your care and support and why, if you wish to say.

Description Details of who is important to you and why. They could be family members, carers, friends, members of staff etc. Include how you want the people important to you to be engaged and involved in your care and support in both emergency and normal situations. Include how you stay connected to the people important to you. Who should not be contacted or consulted about your care and support and why, if you wish to say
Operationalization Free text 
Value Domain
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft How I communicate and how to communicate with me 0 … 1
prsb03-dataelement-13006
Id prsb03-dataelement-13006 (2020‑04‑24 11:48:24) 0.3
Cardinality 0 … 1
Description A description of how you communicate normally. 
Source SNOMED CT Tag : - 428330008 | Preferred mode of communication (observable entity) |
target Used by one transaction, 0 templates, inherited 0 times
 
draft How I communicate and how to communicate with me 0 … 1
prsb03-dataelement-14329
Id prsb03-dataelement-14329 (2021‑07‑01 16:39:25)
Cardinality 0 … 1
Context
A description of how you communicate normally including any communication aids you use, for example a hearing aid. 
  • Include your preferred language of communication, if your first language is not English. 
  • Include how you would communicate when you are in pain or distress. Include how you communicate choices.
  • Include how you give feedback or raise a concern.
  • Include how you like to receive information.
  • Describe how you would like others to engage and communicate with you, including how you would like to be addressed.

Description

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

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

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

Operationalization Free text
Value Domain
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft My wellness 0 … 1
prsb03-dataelement-13005
Id prsb03-dataelement-13005 (2020‑04‑24 11:45:53)
Cardinality 0 … 1
Synonym
0.3
Description A description covering what you are able to do, how you engage with others and how you feel on a typical day through to on a day when you are unwell or really unwell.
Source SNOMED CT Tag : - 363800008 | General wellbeing (observable entity) |
target Used by one transaction, 0 templates, inherited 0 times
 
draft My wellness 0 … 1
prsb03-dataelement-14331
Id prsb03-dataelement-14331 (2021‑07‑01 16:58:12)
Cardinality 0 … 1
Context
A description covering what you are able to do, how you engage with others and how you feel on a typical day through to on a day when you are unwell or really unwell.
  • Include any causes that might result in you becoming unwell and strategies for avoiding or addressing the causes. For example, not drinking enough water could cause constipation.
  • Include any signs that indicate you might be becoming unwell.
  • On a bad day describe what is different about what you are able to do, how you engage with others and how you feel.
  • Include how your everyday life is affected by any medical conditions, e.g., dementia or symptoms, e.g., itchiness, cough or pain, and how you manage those conditions.
  • Include past health issues or experiences that need to be considered
  • Include your wellbeing and lifestyle goals and aspirations
Description

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

  • Include any causes that might result in you becoming unwell and strategies for avoiding or addressing the causes. For example, not drinking enough water could cause constipation.
  • Include any signs that indicate you might be becoming unwell.
  • On a bad day describe what is different about what you are able to do, how you engage with others and how you feel.
  • Include how your everyday life is affected by any medical conditions e.g. dementia and any symptoms e.g. itchiness, cough, pain and how you manage those conditions.
  • Include past health issues or experiences that need to be considered
  • Include your wellbeing and lifestyle goals and aspirations
    Operationalization Free text
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Please do and please don't 0 … 1
    prsb03-dataelement-13008
    Id prsb03-dataelement-13008 (2020‑04‑27 10:34:59) 0.3
    Cardinality 0 … 1
    Description A description of things you want someone supporting you to do (or not to do). 
    Source SNOMED CT Tag : - 414642003 | Making considered choices (observable entity) |
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Please do and please don't 0 … 1
    prsb03-dataelement-14333
    Id prsb03-dataelement-14333 (2021‑07‑01 17:26:02)
    Cardinality 0 … 1
    Description A description of things you want someone supporting you to do (or not to do).
    Things you want someone to do might include (for example): - Talk to me not to my carer, remind me to take my medication, encourage me to wash my hands regularly, explain to me what is happening and why, respond to my communication.
    A description of things you do not want someone supporting you to do might include (for example): - Discussing or asking questions about certain topics, making assumptions about something, providing support when it is not wanted, talking to you in a certain way, undergoing a specific intervention or taking a medication the person does not want.
    Operationalization Free text
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft How and when to support me 0 … 1
    prsb03-dataelement-13007
    Id prsb03-dataelement-13007 (2020‑04‑27 10:29:54) 0.3
    Cardinality 0 … 1
    Description A description of how and when you want someone caring for you to support you.
    Source SNOMED CT Tag: -  1364521000000106 |Trigger factor to activate care plan (observable entity)|
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft How and when to support me 0 … 1
    prsb03-dataelement-14335
    Id prsb03-dataelement-14335 (2021‑07‑01 17:35:20)
    Cardinality 0 … 1
    Context
    A description of how and when you want someone caring for you to support you. This could include support needs in an emergency situation (for example taking blood).

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

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

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

    Operationalization Free text
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Also worth knowing about me 0 … 1
    prsb03-dataelement-13094
    Id prsb03-dataelement-13094 (2020‑06‑22 11:30:09) 0.2
    Cardinality 0 … 1
    Description A description of what is also worth knowing about you for people caring or supporting you. 
    Source SNOMED CT Tag: - 160476009 | Social / personal history observable (observable entity) |

    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Also worth knowing about me 0 … 1
    prsb03-dataelement-14337
    Id prsb03-dataelement-14337 (2021‑07‑01 17:41:50)
    Cardinality 0 … 1
    Context
    A description of what is also worth knowing about you for people caring or supporting you. This could include a short history of your life (where you have worked, where you lived, important events in your life, important people in your past life).

    This could include a short profile of your current life:
    • your work and/or study
    • your aspirations
    • your skills
    • your networks
    • things you like e.g. particular foods, places, a football team and things you like to talk about.
    • things you dislike
     This could also include any care and support preferences that have not been included elsewhere.

    Description

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

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

    Operationalization Free text
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Date 0 … 1
    prsb03-dataelement-10367
    Id prsb03-dataelement-10367 (2018‑10‑31)
    Cardinality 0 … 1
    Description This is a record of the date that this information was last updated.
    Operationalization Date and Time
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Supported to write this by 0 … 1
    prsb03-dataelement-10368
    Id prsb03-dataelement-10368 (2018‑10‑31)
    Cardinality 0 … 1
    Description Where relevant, this is a record of name, relationship/role and contact details of the individual who supported the person to write this section e.g. carer, family member, advocate, professional.
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Location to multimedia file 0 … 1
    prsb03-dataelement-14326
    Id prsb03-dataelement-14326 (2021‑07‑01 13:50:03)
    Cardinality 0 … 1
    Description The link to the person's multimedia file
    Operationalization Link to URL
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Individual requirements 0 … 1
    prsb03-dataelement-160
    Id prsb03-dataelement-160 (2018‑10‑31)
    Cardinality 0 … 1
    Context
    This section allows for the sharing of any individual requirements the person may have, such as to support cognitive impairment or mobility issues. This may relate to special needs and would extend to include a record of reasonable adjustments which would be included in ‘Other individual requirements’. 
    Specific disabilities would be included in the ’Problem list’ section however the requirements to support the disabilities (e.g. needs wheelchair access, needs large print etc.) would be included in this section.
    The accessible information requirements information would be the most recent requirement rather than a history of requirements. 
    Description The individual requirements of the person.
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Reasonable adjustment 0 … 1
    prsb03-dataelement-12991
    Id prsb03-dataelement-12991 (2020‑04‑23 19:50:39)
    Cardinality 0 … 1
    Description A record of reasonable adjustments that must be provided by the service to comply with the Equality Act 2010.
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Reasonable adjustment record entry 0 … *
    prsb03-dataelement-13061
    Id prsb03-dataelement-13061 (2020‑05‑12 14:38:35)
    Cardinality 0 … *
    Description 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
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Location 0 … 1
    prsb03-dataelement-13098
    Id prsb03-dataelement-13098 (2020‑06‑24 11:17:33)
    Cardinality 0 … 1
    Description The location where the reasonable adjustment was identified.
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Coded value 0 … 1
    prsb03-dataelement-13357
    Id prsb03-dataelement-13357 (2020‑08‑06 17:41:52)
    Cardinality 0 … 1
    Description The coded value for location.
    Operationalization NHS Data dictionary : - Organisation data service code
    Value Domain
    Property
    min length max length
    3 5
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Free text 0 … 1
    prsb03-dataelement-13358
    Id prsb03-dataelement-13358 (2020‑08‑06 17:44:19)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
    Description Free text field to be used if no code is available
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Reasonable adjustment 0 … 1
    prsb03-dataelement-13017
    Id prsb03-dataelement-13017 (2020‑04‑28 18:57:15)
    Cardinality 0 … 1
    Description The reasonable adjustment required e.g. requires specific contact method, requires communication professional
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Coded value 0 … 1
    prsb03-dataelement-13505
    Id prsb03-dataelement-13505 (2020‑09‑02 18:40:38)
    Cardinality 0 … 1
    Description The coded value for reasonable adjustment
    Operationalization SNOMED 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
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Free text 0 … 1
    prsb03-dataelement-13506
    Id prsb03-dataelement-13506 (2020‑09‑02 18:41:44)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
    Description Free text field to be used if no code is available
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Reasonable adjustment additional detail 0 … 1
    prsb03-dataelement-13018
    Id prsb03-dataelement-13018 (2020‑04‑28 19:01:03)
    Cardinality 0 … 1
    Description Further detail about the support required and the consequence of not providing it.
    Operationalization Free text
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Date 0 … 1
    prsb03-dataelement-13020
    Id prsb03-dataelement-13020 (2020‑04‑28 19:14:37)
    Cardinality 0 … 1
    Description The date the reasonable adjustment was identified.
    Operationalization Date and time
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Performing professional 0 … 1
    prsb03-dataelement-13027
    Id prsb03-dataelement-13027 (2020‑04‑28 19:30:46)
    Cardinality 0 … 1
    Description The professional who confirmed the need for the reasonable adjustment.
    Relationship
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Name 0 … 1
    prsb03-dataelement-13028
    Id prsb03-dataelement-13028 (2020‑04‑28 19:31:24)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-12185 (2019‑05‑31 16:19:35)
    Description The name of the professional.
    Rationale Practitioner.name
    Operationalization Free text.
    Value Domain
    Property
    max length
    70
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Role 0 … 1
    prsb03-dataelement-13029
    Id prsb03-dataelement-13029 (2020‑04‑28 19:31:24)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-12186 (2019‑05‑31 16:19:35)
    Description The role the professional has in relation to the person.
    Relationship
    Operationalization FHIR value set : - sdsjobrole
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Grade 0 … 1
    prsb03-dataelement-13030
    Id prsb03-dataelement-13030 (2020‑04‑28 19:31:24)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-12187 (2019‑05‑31 16:19:35)
    Description The grade of the professional.
    Rationale PractitionerRole.code
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Speciality 0 … 1
    prsb03-dataelement-13031
    Id prsb03-dataelement-13031 (2020‑04‑28 19:31:24)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-12188 (2019‑05‑31 16:19:35)
    Description The specialty of the professional.
    Relationship
    Operationalization NHS data dictionary - Main specialty code
    Value Domain
    Property
    max length
    3
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Professional identifier 0 … 1
    prsb03-dataelement-13032
    Id prsb03-dataelement-13032 (2020‑04‑28 19:31:24)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-12189 (2019‑05‑31 16:19:35)
    Description Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.
    Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
    Operationalization NHS data dictionary : - Professional registration identifier
    Value Domain
    Property
    max length
    32
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Organisation 0 … 1
    prsb03-dataelement-13033
    Id prsb03-dataelement-13033 (2020‑04‑28 19:31:24)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-12190 (2019‑05‑31 16:19:35)
    Description The name of the organisation the professional works for.
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Contact details 0 … 1
    prsb03-dataelement-13034
    Id prsb03-dataelement-13034 (2020‑04‑28 19:31:24)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-12191 (2019‑05‑31 16:19:35)
    Description Contact details of the professional
    Rationale Practitioner.telecom

    PractitionerRole.telecom

    Organisation.telcom
    Operationalization NHS data dictionary - UK phone number
    Value Domain
    Property
    max length
    35
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Person completing record 0 … 1
    prsb03-dataelement-13035
    Id prsb03-dataelement-13035 (2020‑04‑28 19:33:13)
    Cardinality 0 … 1
    Description A record of the details of the person that entered the reasonable adjustment and the date on which it was entered.
    Relationship
    target Used by one transaction, 0 templates, inherited once
     
    draft Name 0 … 1
    prsb03-dataelement-13036
    Id prsb03-dataelement-13036 (2020‑04‑28 19:33:40)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11290 (2019‑05‑30 12:25:39)
    Description The name of the person completing the record.
    Relationship
    Rationale Composition.author.Practitioner.name
    Operationalization Free text.
    Value Domain
    Property
    max length
    70
    target Used by one transaction, 0 templates, inherited 3 times
     
    draft Role 0 … 1
    prsb03-dataelement-13037
    Id prsb03-dataelement-13037 (2020‑04‑28 19:33:40)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
    Description The organisational role of the person completing record.

    Properties

    FHIR PractitionerRole.code of the practitioner completing the record
    Relationship
    Rationale Composition.author.Practitioner.PractitionerRole.code
    Operationalization FHIR value set :- SDSjobrole
    Value Domain
    target Used by one transaction, 0 templates, inherited 3 times
     
    draft Grade 0 … 1
    prsb03-dataelement-13038
    Id prsb03-dataelement-13038 (2020‑04‑28 19:33:40)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11292 (2019‑05‑30 12:25:39)
    Description The grade of the person completing the record.
    Relationship
    Rationale PractitionerRole.code
    Operationalization Free text.
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 3 times
     
    draft Specialty 0 … 1
    prsb03-dataelement-13039
    Id prsb03-dataelement-13039 (2020‑04‑28 19:33:40)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11293 (2019‑05‑30 12:25:39)
    Description The main specialty of the person completing the record.

    Properties

    FHIR PractitionerRole.specialty
    Relationship
    Rationale PractitionerRole.speciality
    Operationalization NHS data dictionary :- Activity treatment function code
    Value Domain
    Property
    max length
    3
    target Used by one transaction, 0 templates, inherited 3 times
     
    folder draft Organisation 0 … 1
    prsb03-dataelement-13040
    Id prsb03-dataelement-13040 (2020‑04‑28 19:33:40)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
    Description The organisation the person completing the record works for.
    Relationship
    Operationalization NHS data dictionary : - Organisation data service
    target Used by one transaction, 0 templates, inherited 3 times
     
    draft Professional identifier 0 … 1
    prsb03-dataelement-13041
    Id prsb03-dataelement-13041 (2020‑04‑28 19:33:40)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11295 (2019‑05‑30 12:25:39)
    Description Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.

    Properties

    FHIR PractitionerRole.Practitioner.identifier (local) Practitioner.identifer (professional)
    Relationship
    Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
    Operationalization NHS data dictionary :- Professional registration identifier
    Value Domain
    Property
    max length
    32
    target Used by one transaction, 0 templates, inherited 3 times
     
    draft Date completed 0 … 1
    prsb03-dataelement-13042
    Id prsb03-dataelement-13042 (2020‑04‑28 19:33:40)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11296 (2019‑05‑30 12:25:39)
    Description The date and time the record was completed.
    Relationship
    Rationale Composition.date
    Operationalization Date and time.
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited 3 times
     
    draft Contact details 0 … 1
    prsb03-dataelement-13043
    Id prsb03-dataelement-13043 (2020‑04‑28 19:33:40)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
    Description Contact details of the person completing the record.

    Properties

    FHIR PractitionerRole.telecom
    Relationship
    Rationale Practitioner.telecom

    PractitionerRole.telecom

    Organisation.telcom
    Operationalization NHS data dictionary : - UK telephone number
    Value Domain
    Property
    max length
    35
    target Used by one transaction, 0 templates, inherited 3 times
     
    folder draft Impairment 0 … 1
    prsb03-dataelement-13001
    Id prsb03-dataelement-13001 (2020‑04‑23 20:09:01)
    Cardinality 0 … 1
    Description A record of any impairments for the person relating to reasonable adjustments.
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Impairment record entry 0 … *
    prsb03-dataelement-13062
    Id prsb03-dataelement-13062 (2020‑05‑12 15:52:51)
    Cardinality 0 … *
    Description This is an impairment record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Location 0 … 1
    prsb03-dataelement-13099
    Id prsb03-dataelement-13099 (2020‑06‑24 11:19:59)
    Cardinality 0 … 1
    Description The location where the impairment was identified.
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Coded value 0 … 1
    prsb03-dataelement-13429
    Id prsb03-dataelement-13429 (2020‑08‑13 15:01:40)
    Cardinality 0 … 1
    Description The coded value for location.
    Operationalization NHS data dictionary: - Organisation code service
    Value Domain
    Property
    min length max length
    3 5
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Free text 0 … 1
    prsb03-dataelement-13430
    Id prsb03-dataelement-13430 (2020‑08‑13 15:38:25)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
    Description Free text field to be used if no code is available
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Impairment category 0 … 1
    prsb03-dataelement-13022
    Id prsb03-dataelement-13022 (2020‑04‑28 19:21:25)
    Cardinality 0 … 1
    Description
    The category of the impairment e.g. Autism, Dementia, Physical disability, Sensory disability - such as sight or hearing, Long-term condition
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Coded value 0 … 1
    prsb03-dataelement-13507
    Id prsb03-dataelement-13507 (2020‑09‑02 18:45:17)
    Cardinality 0 … 1
    Description The coded value for impairment.
    Operationalization SNOMED CT
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Free text 0 … 1
    prsb03-dataelement-13508
    Id prsb03-dataelement-13508 (2020‑09‑02 18:46:00)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
    Description Free text field to be used if no code is available
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Impairment additional detail 0 … 1
    prsb03-dataelement-13023
    Id prsb03-dataelement-13023 (2020‑04‑28 19:23:16)
    Cardinality 0 … 1
    Description

    Description of what the person can do with the impairment, what they want to be able to do and how they should be supported to do it and what the consequences are of not providing the support.
    Where there is a sensory disability include sensory processing difficulties (e.g. affects to balance and movement, oversensitive, under-sensitive).
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Date 0 … 1
    prsb03-dataelement-13024
    Id prsb03-dataelement-13024 (2020‑04‑28 19:24:22)
    Cardinality 0 … 1
    Description The date the impairment was identified.
    Operationalization Date and time
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Performing professional 0 … 1
    prsb03-dataelement-13044
    Id prsb03-dataelement-13044 (2020‑04‑28 19:34:59)
    Cardinality 0 … 1
    Description The professional who confirmed the impairment.
    Relationship
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Name 0 … 1
    prsb03-dataelement-13045
    Id prsb03-dataelement-13045 (2020‑04‑28 19:35:28)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-12028 (2019‑05‑31 15:30:50)
    Description The name of the professional.
    Rationale Practitioner.name
    Operationalization Free text.
    Value Domain
    Property
    max length
    70
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Role 0 … 1
    prsb03-dataelement-13046
    Id prsb03-dataelement-13046 (2020‑04‑28 19:35:28)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-12029 (2019‑05‑31 15:30:50)
    Description The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc
    Rationale Practitioner.PractitionerRole.code
    Operationalization FHIR value set :- SDSjobroletype
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Grade 0 … 1
    prsb03-dataelement-13047
    Id prsb03-dataelement-13047 (2020‑04‑28 19:35:28)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-12030 (2019‑05‑31 15:30:50)
    Description The grade of the professional.
    Rationale PractitionerRole.code
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Speciality 0 … 1
    prsb03-dataelement-13048
    Id prsb03-dataelement-13048 (2020‑04‑28 19:35:28)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-12031 (2019‑05‑31 15:30:50)
    Description The specialty of the professional e.g. physiotherapy, oncology, mental health etc
    Rationale PractitionerRole.speciality
    Operationalization NHS data dictionary - Activity treatment function code
    Value Domain
    Property
    max length
    3
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Professional identifier 0 … 1
    prsb03-dataelement-13049
    Id prsb03-dataelement-13049 (2020‑04‑28 19:35:28)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-12032 (2019‑05‑31 15:30:50)
    Description Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.
    Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
    Operationalization NHS data dictionary : - Professional registration identifier
    Value Domain
    Property
    max length
    32
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Organisation 0 … 1
    prsb03-dataelement-13050
    Id prsb03-dataelement-13050 (2020‑04‑28 19:35:28)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-12033 (2019‑05‑31 15:30:50)
    Description The name of the organisation the professional works for.
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Contact details 0 … 1
    prsb03-dataelement-13051
    Id prsb03-dataelement-13051 (2020‑04‑28 19:35:28)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-12034 (2019‑05‑31 15:30:50)
    Description Contact details of the professional
    Rationale Practitioner.telecom

    PractitionerRole.telecom

    Organisation.telcom
    Operationalization NHS data dictionary - UK phone number
    Value Domain
    Property
    max length
    35
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Person completing record 0 … 1
    prsb03-dataelement-13052
    Id prsb03-dataelement-13052 (2020‑04‑28 19:36:14)
    Cardinality 0 … 1
    Description
    A record of the details of the person that entered the impairment and the date on which it was entered.
    Relationship
    target Used by one transaction, 0 templates, inherited once
     
    draft Name 0 … 1
    prsb03-dataelement-13053
    Id prsb03-dataelement-13053 (2020‑04‑28 19:36:38)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11290 (2019‑05‑30 12:25:39)
    Description The name of the person completing the record.
    Relationship
    Rationale Composition.author.Practitioner.name
    Operationalization Free text.
    Value Domain
    Property
    max length
    70
    target Used by one transaction, 0 templates, inherited 2 times
     
    draft Role 0 … 1
    prsb03-dataelement-13054
    Id prsb03-dataelement-13054 (2020‑04‑28 19:36:38)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
    Description The organisational role of the person completing record.

    Properties

    FHIR PractitionerRole.code of the practitioner completing the record
    Relationship
    Rationale Composition.author.Practitioner.PractitionerRole.code
    Operationalization FHIR value set :- SDSjobrole
    Value Domain
    target Used by one transaction, 0 templates, inherited 2 times
     
    draft Grade 0 … 1
    prsb03-dataelement-13055
    Id prsb03-dataelement-13055 (2020‑04‑28 19:36:38)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11292 (2019‑05‑30 12:25:39)
    Description The grade of the person completing the record.
    Relationship
    Rationale PractitionerRole.code
    Operationalization Free text.
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 2 times
     
    draft Specialty 0 … 1
    prsb03-dataelement-13056
    Id prsb03-dataelement-13056 (2020‑04‑28 19:36:38)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11293 (2019‑05‑30 12:25:39)
    Description The main specialty of the person completing the record.

    Properties

    FHIR PractitionerRole.specialty
    Relationship
    Rationale PractitionerRole.speciality
    Operationalization NHS data dictionary :- Activity treatment function code
    Value Domain
    Property
    max length
    3
    target Used by one transaction, 0 templates, inherited 2 times
     
    folder draft Organisation 0 … 1
    prsb03-dataelement-13057
    Id prsb03-dataelement-13057 (2020‑04‑28 19:36:38)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
    Description The organisation the person completing the record works for.
    Relationship
    Operationalization NHS data dictionary : - Organisation data service
    target Used by one transaction, 0 templates, inherited 2 times
     
    draft Professional identifier 0 … 1
    prsb03-dataelement-13058
    Id prsb03-dataelement-13058 (2020‑04‑28 19:36:38)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11295 (2019‑05‑30 12:25:39)
    Description Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.

    Properties

    FHIR PractitionerRole.Practitioner.identifier (local) Practitioner.identifer (professional)
    Relationship
    Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
    Operationalization NHS data dictionary :- Professional registration identifier
    Value Domain
    Property
    max length
    32
    target Used by one transaction, 0 templates, inherited 2 times
     
    draft Date completed 0 … 1
    prsb03-dataelement-13059
    Id prsb03-dataelement-13059 (2020‑04‑28 19:36:38)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11296 (2019‑05‑30 12:25:39)
    Description The date and time the record was completed.
    Relationship
    Rationale Composition.date
    Operationalization Date and time.
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited 2 times
     
    draft Contact details 0 … 1
    prsb03-dataelement-13060
    Id prsb03-dataelement-13060 (2020‑04‑28 19:36:38)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
    Description Contact details of the person completing the record.

    Properties

    FHIR PractitionerRole.telecom
    Relationship
    Rationale Practitioner.telecom

    PractitionerRole.telecom

    Organisation.telcom
    Operationalization NHS data dictionary : - UK telephone number
    Value Domain
    Property
    max length
    35
    target Used by one transaction, 0 templates, inherited 2 times
     
    folder draft Cognition 0 … *
    prsb03-dataelement-10066
    Id prsb03-dataelement-10066 (2018‑10‑31)
    Cardinality 0 … *
    Description Details of the persons cognitive impairment.
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Date 0 … 1
    prsb03-dataelement-11705
    Id prsb03-dataelement-11705 (2019‑05‑31 13:05:51)
    Cardinality 0 … 1
    Description The date when the cognitive impairment was identified.
    Relationship
    Operationalization Date and time
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Location 0 … 1
    prsb03-dataelement-11706
    Id prsb03-dataelement-11706 (2019‑05‑31 13:06:37)
    Cardinality 0 … 1
    Description The location where the cognitive impairment was identified.
    Relationship
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Coded value 0 … 1
    prsb03-dataelement-13431
    Id prsb03-dataelement-13431 (2020‑08‑13 15:39:55)
    Cardinality 0 … 1
    Description The coded value for location.
    Operationalization NHS data dictionary : - Organisation data service
    Value Domain
    Property
    min length max length
    3 5
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Free text 0 … 1
    prsb03-dataelement-13432
    Id prsb03-dataelement-13432 (2020‑08‑13 15:41:10)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
    Description Free text field to be used if no code is available
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Cognition 0 … 1
    prsb03-dataelement-13669
    Id prsb03-dataelement-13669 (2020‑09‑08 22:42:26)
    Cardinality 0 … 1
    Description The cognitive impairment to be considered when communicating with the person, child or their primary carer.
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Performing professional 0 … 1
    prsb03-dataelement-11470
    Id prsb03-dataelement-11470 (2019‑05‑30 14:25:03)
    Cardinality 0 … 1
    Description The professional who identified the cognitive impairment.
    Relationship
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Name 0 … 1
    prsb03-dataelement-11471
    Id prsb03-dataelement-11471 (2019‑05‑30 14:25:24)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
    Description The name of the professional.
    Rationale Practitioner.name
    Operationalization Free text.
    Value Domain
    Property
    max length
    70
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Role 0 … 1
    prsb03-dataelement-11472
    Id prsb03-dataelement-11472 (2019‑05‑30 14:25:24)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11283 (2019‑05‑30 11:58:48)
    Description The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc
    Rationale Practitioner.PractitionerRole.code
    Operationalization FHIR value set :- SDSjobroletype
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Grade 0 … 1
    prsb03-dataelement-11473
    Id prsb03-dataelement-11473 (2019‑05‑30 14:25:24)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
    Description The grade of the professional.
    Rationale PractitionerRole.code
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Speciality 0 … 1
    prsb03-dataelement-11474
    Id prsb03-dataelement-11474 (2019‑05‑30 14:25:24)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11284 (2019‑05‑30 12:01:15)
    Description The specialty of the professional e.g. physiotherapy, oncology, mental health etc
    Rationale PractitionerRole.speciality
    Operationalization NHS data dictionary - Activity treatment function code
    Value Domain
    Property
    max length
    3
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Professional identifier 0 … 1
    prsb03-dataelement-11475
    Id prsb03-dataelement-11475 (2019‑05‑30 14:25:24)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11285 (2019‑05‑30 12:02:46)
    Description Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.
    Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
    Operationalization NHS data dictionary : - Professional registration identifier
    Value Domain
    Property
    max length
    32
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Organisation 0 … 1
    prsb03-dataelement-11476
    Id prsb03-dataelement-11476 (2019‑05‑30 14:25:24)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
    Description The name of the organisation the professional works for.
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Contact details 0 … *
    prsb03-dataelement-11477
    Id prsb03-dataelement-11477 (2019‑05‑30 14:25:24)
    Cardinality 0 … *
    Concept inherits from draft prsb03-dataelement-11287 (2019‑05‑30 12:18:13)
    Description Contact details of the professional
    Rationale Practitioner.telecom

    PractitionerRole.telecom

    Organisation.telcom
    Operationalization NHS data dictionary - UK phone number
    Value Domain
    Property
    max length
    35
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Person completing record 0 … 1
    prsb03-dataelement-11478
    Id prsb03-dataelement-11478 (2019‑05‑30 14:25:35)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
    Description Details of the person completing the record.
    Relationship
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Name 0 … 1
    prsb03-dataelement-11479
    Id prsb03-dataelement-11479 (2019‑05‑30 14:26:05)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11290 (2019‑05‑30 12:25:39)
    Description The name of the person completing the record.
    Relationship
    Rationale Composition.author.Practitioner.name
    Operationalization Free text.
    Value Domain
    Property
    max length
    70
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Role 0 … 1
    prsb03-dataelement-11480
    Id prsb03-dataelement-11480 (2019‑05‑30 14:26:05)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
    Description The organisational role of the person completing record.

    Properties

    FHIR PractitionerRole.code of the practitioner completing the record
    Relationship
    Rationale Composition.author.Practitioner.PractitionerRole.code
    Operationalization FHIR value set :- SDSjobrole
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Grade 0 … 1
    prsb03-dataelement-11481
    Id prsb03-dataelement-11481 (2019‑05‑30 14:26:05)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11292 (2019‑05‑30 12:25:39)
    Description The grade of the person completing the record.
    Relationship
    Rationale PractitionerRole.code
    Operationalization Free text.
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Specialty 0 … 1
    prsb03-dataelement-11482
    Id prsb03-dataelement-11482 (2019‑05‑30 14:26:05)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11293 (2019‑05‑30 12:25:39)
    Description The main specialty of the person completing the record.

    Properties

    FHIR PractitionerRole.specialty
    Relationship
    Rationale PractitionerRole.speciality
    Operationalization NHS data dictionary :- Activity treatment function code
    Value Domain
    Property
    max length
    3
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Organisation 0 … 1
    prsb03-dataelement-11483
    Id prsb03-dataelement-11483 (2019‑05‑30 14:26:05)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
    Description The organisation the person completing the record works for.
    Relationship
    Operationalization NHS data dictionary : - Organisation data service
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Professional identifier 0 … 1
    prsb03-dataelement-11484
    Id prsb03-dataelement-11484 (2019‑05‑30 14:26:05)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11295 (2019‑05‑30 12:25:39)
    Description Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.

    Properties

    FHIR PractitionerRole.Practitioner.identifier (local) Practitioner.identifer (professional)
    Relationship
    Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
    Operationalization NHS data dictionary :- Professional registration identifier
    Value Domain
    Property
    max length
    32
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Date completed 0 … 1
    prsb03-dataelement-11485
    Id prsb03-dataelement-11485 (2019‑05‑30 14:26:05)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11296 (2019‑05‑30 12:25:39)
    Description The date and time the record was completed.
    Relationship
    Rationale Composition.date
    Operationalization Date and time.
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Contact details 0 … *
    prsb03-dataelement-11486
    Id prsb03-dataelement-11486 (2019‑05‑30 14:26:05)
    Cardinality 0 … *
    Concept inherits from draft prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
    Description Contact details of the person completing the record.

    Properties

    FHIR PractitionerRole.telecom
    Relationship
    Rationale Practitioner.telecom

    PractitionerRole.telecom

    Organisation.telcom
    Operationalization NHS data dictionary : - UK telephone number
    Value Domain
    Property
    max length
    35
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Mobility 0 … *
    prsb03-dataelement-10067
    Id prsb03-dataelement-10067 (2018‑10‑31)
    Cardinality 0 … *
    Description Details of the person's mobility needs.
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Date 0 … 1
    prsb03-dataelement-11707
    Id prsb03-dataelement-11707 (2019‑05‑31 13:08:03)
    Cardinality 0 … 1
    Description The date when the mobility needs were identified.
    Relationship
    Operationalization Date and time
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Location 0 … 1
    prsb03-dataelement-11710
    Id prsb03-dataelement-11710 (2019‑05‑31 13:11:14)
    Cardinality 0 … 1
    Description The location where the mobility needs were identified.
    Relationship
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Coded value 0 … 1
    prsb03-dataelement-13433
    Id prsb03-dataelement-13433 (2020‑08‑13 15:42:39)
    Cardinality 0 … 1
    Description The coded value for location.
    Operationalization NHS data dictionary : - Organisation data service
    Value Domain
    Property
    min length max length
    3 5
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Free text 0 … 1
    prsb03-dataelement-13434
    Id prsb03-dataelement-13434 (2020‑08‑13 15:44:10)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13223 (2020‑07‑08 17:40:09)
    Description Free text field to be used if no coded text available
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Mobility needs 0 … 1
    prsb03-dataelement-13670
    Id prsb03-dataelement-13670 (2020‑09‑08 22:45:14)
    Cardinality 0 … 1
    Description The mobility needs of the person that allows movement between two spaces and achieves participation and a degree of independence.
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Coded value 0 … 1
    prsb03-dataelement-13671
    Id prsb03-dataelement-13671 (2020‑09‑08 22:47:06)
    Cardinality 0 … 1
    Description The coded value for mobility needs
    Operationalization SNOMED CT: - ^999002551000000108 |Mobility findings simple reference set (foundation metadata concept)|
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Free text 0 … 1
    prsb03-dataelement-13672
    Id prsb03-dataelement-13672 (2020‑09‑08 22:47:50)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
    Description Free text field to be used if no code is available
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Performing professional 0 … 1
    prsb03-dataelement-11487
    Id prsb03-dataelement-11487 (2019‑05‑30 14:26:29)
    Cardinality 0 … 1
    Description The professional who identified the mobility needs.
    Relationship
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Name 0 … 1
    prsb03-dataelement-11488
    Id prsb03-dataelement-11488 (2019‑05‑30 14:27:10)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
    Description The name of the professional.
    Rationale Practitioner.name
    Operationalization Free text.
    Value Domain
    Property
    max length
    70
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Role 0 … 1
    prsb03-dataelement-11489
    Id prsb03-dataelement-11489 (2019‑05‑30 14:27:10)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11283 (2019‑05‑30 11:58:48)
    Description The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc
    Rationale Practitioner.PractitionerRole.code
    Operationalization FHIR value set :- SDSjobroletype
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Grade 0 … 1
    prsb03-dataelement-11490
    Id prsb03-dataelement-11490 (2019‑05‑30 14:27:10)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
    Description The grade of the professional.
    Rationale PractitionerRole.code
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Speciality 0 … 1
    prsb03-dataelement-11491
    Id prsb03-dataelement-11491 (2019‑05‑30 14:27:10)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11284 (2019‑05‑30 12:01:15)
    Description The specialty of the professional e.g. physiotherapy, oncology, mental health etc
    Rationale PractitionerRole.speciality
    Operationalization NHS data dictionary - Activity treatment function code
    Value Domain
    Property
    max length
    3
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Professional identifier 0 … 1
    prsb03-dataelement-11492
    Id prsb03-dataelement-11492 (2019‑05‑30 14:27:10)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11285 (2019‑05‑30 12:02:46)
    Description Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.
    Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
    Operationalization NHS data dictionary : - Professional registration identifier
    Value Domain
    Property
    max length
    32
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Organisation 0 … 1
    prsb03-dataelement-11493
    Id prsb03-dataelement-11493 (2019‑05‑30 14:27:10)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
    Description The name of the organisation the professional works for.
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Contact details 0 … *
    prsb03-dataelement-11494
    Id prsb03-dataelement-11494 (2019‑05‑30 14:27:10)
    Cardinality 0 … *
    Concept inherits from draft prsb03-dataelement-11287 (2019‑05‑30 12:18:13)
    Description Contact details of the professional
    Rationale Practitioner.telecom

    PractitionerRole.telecom

    Organisation.telcom
    Operationalization NHS data dictionary - UK phone number
    Value Domain
    Property
    max length
    35
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Person completing record 0 … 1
    prsb03-dataelement-11495
    Id prsb03-dataelement-11495 (2019‑05‑30 14:27:24)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
    Description Details of the person completing the record.
    Relationship
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Name 0 … 1
    prsb03-dataelement-11496
    Id prsb03-dataelement-11496 (2019‑05‑30 14:27:45)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11290 (2019‑05‑30 12:25:39)
    Description The name of the person completing the record.
    Relationship
    Rationale Composition.author.Practitioner.name
    Operationalization Free text.
    Value Domain
    Property
    max length
    70
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Role 0 … 1
    prsb03-dataelement-11497
    Id prsb03-dataelement-11497 (2019‑05‑30 14:27:45)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
    Description The organisational role of the person completing record.

    Properties

    FHIR PractitionerRole.code of the practitioner completing the record
    Relationship
    Rationale Composition.author.Practitioner.PractitionerRole.code
    Operationalization FHIR value set :- SDSjobrole
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Grade 0 … 1
    prsb03-dataelement-11498
    Id prsb03-dataelement-11498 (2019‑05‑30 14:27:45)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11292 (2019‑05‑30 12:25:39)
    Description The grade of the person completing the record.
    Relationship
    Rationale PractitionerRole.code
    Operationalization Free text.
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Specialty 0 … 1
    prsb03-dataelement-11499
    Id prsb03-dataelement-11499 (2019‑05‑30 14:27:45)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11293 (2019‑05‑30 12:25:39)
    Description The main specialty of the person completing the record.

    Properties

    FHIR PractitionerRole.specialty
    Relationship
    Rationale PractitionerRole.speciality
    Operationalization NHS data dictionary :- Activity treatment function code
    Value Domain
    Property
    max length
    3
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Organisation 0 … 1
    prsb03-dataelement-11500
    Id prsb03-dataelement-11500 (2019‑05‑30 14:27:45)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
    Description The organisation the person completing the record works for.
    Relationship
    Operationalization NHS data dictionary : - Organisation data service
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Professional identifier 0 … 1
    prsb03-dataelement-11501
    Id prsb03-dataelement-11501 (2019‑05‑30 14:27:45)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11295 (2019‑05‑30 12:25:39)
    Description Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.

    Properties

    FHIR PractitionerRole.Practitioner.identifier (local) Practitioner.identifer (professional)
    Relationship
    Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
    Operationalization NHS data dictionary :- Professional registration identifier
    Value Domain
    Property
    max length
    32
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Date completed 0 … 1
    prsb03-dataelement-11502
    Id prsb03-dataelement-11502 (2019‑05‑30 14:27:45)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11296 (2019‑05‑30 12:25:39)
    Description The date and time the record was completed.
    Relationship
    Rationale Composition.date
    Operationalization Date and time.
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Contact details 0 … *
    prsb03-dataelement-11503
    Id prsb03-dataelement-11503 (2019‑05‑30 14:27:45)
    Cardinality 0 … *
    Concept inherits from draft prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
    Description Contact details of the person completing the record.

    Properties

    FHIR PractitionerRole.telecom
    Relationship
    Rationale Practitioner.telecom

    PractitionerRole.telecom

    Organisation.telcom
    Operationalization NHS data dictionary : - UK telephone number
    Value Domain
    Property
    max length
    35
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Other individual requirements 0 … *
    prsb03-dataelement-10835
    Id prsb03-dataelement-10835 (2019‑03‑22 16:24:41)
    Cardinality 0 … *
    Description Details of any other individual requirements the person may have
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Date 0 … 1
    prsb03-dataelement-11711
    Id prsb03-dataelement-11711 (2019‑05‑31 13:12:01)
    Cardinality 0 … 1
    Description The date when the other individual requirements were identified.
    Relationship
    Operationalization Date and time
    Value Domain
    Property
    Timestamp precision
    at least day, month and year
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Location 0 … 1
    prsb03-dataelement-11712
    Id prsb03-dataelement-11712 (2019‑05‑31 13:12:31)
    Cardinality 0 … 1
    Description The location where the other individual requirements were identified.
    Relationship
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Coded value 0 … 1
    prsb03-dataelement-13435
    Id prsb03-dataelement-13435 (2020‑08‑13 15:46:58)
    Cardinality 0 … 1
    Description The coded value for location.
    Operationalization NHS data dictionary : - Organisation service code
    Value Domain
    Property
    min length max length
    3 5
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Free text 0 … 1
    prsb03-dataelement-13436
    Id prsb03-dataelement-13436 (2020‑08‑13 15:48:03)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13223 (2020‑07‑08 17:40:09)
    Description Free text field to be used if no coded text available
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Other individual requirement 0 … 1
    prsb03-dataelement-13673
    Id prsb03-dataelement-13673 (2020‑09‑08 22:51:48)
    Cardinality 0 … 1
    Description Other individual requirements that a person may have.
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Performing professional 0 … 1
    prsb03-dataelement-11504
    Id prsb03-dataelement-11504 (2019‑05‑30 14:34:59)
    Cardinality 0 … 1
    Description The professional who identified the other individual requirements.
    Relationship
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Name 0 … 1
    prsb03-dataelement-11505
    Id prsb03-dataelement-11505 (2019‑05‑30 14:35:29)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
    Description The name of the professional.
    Rationale Practitioner.name
    Operationalization Free text.
    Value Domain
    Property
    max length
    70
    target Used by one transaction, 0 templates, inherited once
     
    draft Role 0 … 1
    prsb03-dataelement-11506
    Id prsb03-dataelement-11506 (2019‑05‑30 14:35:29)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11283 (2019‑05‑30 11:58:48)
    Description The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc
    Rationale Practitioner.PractitionerRole.code
    Operationalization FHIR value set :- SDSjobroletype
    Value Domain
    target Used by one transaction, 0 templates, inherited once
     
    draft Grade 0 … 1
    prsb03-dataelement-11507
    Id prsb03-dataelement-11507 (2019‑05‑30 14:35:29)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
    Description The grade of the professional.
    Rationale PractitionerRole.code
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited once
     
    draft Speciality 0 … 1
    prsb03-dataelement-11508
    Id prsb03-dataelement-11508 (2019‑05‑30 14:35:29)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11284 (2019‑05‑30 12:01:15)
    Description The specialty of the professional e.g. physiotherapy, oncology, mental health etc
    Rationale PractitionerRole.speciality
    Operationalization NHS data dictionary - Activity treatment function code
    Value Domain
    Property
    max length
    3
    target Used by one transaction, 0 templates, inherited once
     
    draft Professional identifier 0 … 1
    prsb03-dataelement-11509
    Id prsb03-dataelement-11509 (2019‑05‑30 14:35:29)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11285 (2019‑05‑30 12:02:46)
    Description Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.
    Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
    Operationalization NHS data dictionary : - Professional registration identifier
    Value Domain
    Property
    max length
    32
    target Used by one transaction, 0 templates, inherited once
     
    folder draft Organisation 0 … 1
    prsb03-dataelement-11510
    Id prsb03-dataelement-11510 (2019‑05‑30 14:35:29)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
    Description The name of the organisation the professional works for.
    target Used by one transaction, 0 templates, inherited once
     
    draft Contact details 0 … *
    prsb03-dataelement-11511
    Id prsb03-dataelement-11511 (2019‑05‑30 14:35:29)
    Cardinality 0 … *
    Concept inherits from draft prsb03-dataelement-11287 (2019‑05‑30 12:18:13)
    Description Contact details of the professional
    Rationale Practitioner.telecom

    PractitionerRole.telecom

    Organisation.telcom
    Operationalization NHS data dictionary - UK phone number
    Value Domain
    Property
    max length
    35
    target Used by one transaction, 0 templates, inherited once
     
    folder draft Person completing record 0 … 1
    prsb03-dataelement-11512
    Id prsb03-dataelement-11512 (2019‑05‑30 14:35:41)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
    Description Details of the person completing the record.
    Relationship
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Name 0 … 1
    prsb03-dataelement-11513
    Id prsb03-dataelement-11513 (2019‑05‑30 14:36:02)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11290 (2019‑05‑30 12:25:39)
    Description The name of the person completing the record.
    Relationship
    Rationale Composition.author.Practitioner.name
    Operationalization Free text.
    Value Domain
    Property
    max length
    70
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Role 0 … 1
    prsb03-dataelement-11514
    Id prsb03-dataelement-11514 (2019‑05‑30 14:36:02)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
    Description The organisational role of the person completing record.

    Properties

    FHIR PractitionerRole.code of the practitioner completing the record
    Relationship
    Rationale Composition.author.Practitioner.PractitionerRole.code
    Operationalization FHIR value set :- SDSjobrole
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Grade 0 … 1
    prsb03-dataelement-11515
    Id prsb03-dataelement-11515 (2019‑05‑30 14:36:02)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11292 (2019‑05‑30 12:25:39)
    Description The grade of the person completing the record.
    Relationship
    Rationale PractitionerRole.code
    Operationalization Free text.
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Specialty 0 … 1
    prsb03-dataelement-11516
    Id prsb03-dataelement-11516 (2019‑05‑30 14:36:02)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11293 (2019‑05‑30 12:25:39)
    Description The main specialty of the person completing the record.

    Properties

    FHIR PractitionerRole.specialty
    Relationship
    Rationale PractitionerRole.speciality
    Operationalization NHS data dictionary :- Activity treatment function code
    Value Domain
    Property
    max length
    3
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Organisation 0 … 1
    prsb03-dataelement-11517
    Id prsb03-dataelement-11517 (2019‑05‑30 14:36:02)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
    Description The organisation the person completing the record works for.
    Relationship
    Operationalization NHS data dictionary : - Organisation data service
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Professional identifier 0 … 1
    prsb03-dataelement-11518
    Id prsb03-dataelement-11518 (2019‑05‑30 14:36:02)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11295 (2019‑05‑30 12:25:39)
    Description Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.

    Properties

    FHIR PractitionerRole.Practitioner.identifier (local) Practitioner.identifer (professional)
    Relationship
    Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
    Operationalization NHS data dictionary :- Professional registration identifier
    Value Domain
    Property
    max length
    32
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Date completed 0 … 1
    prsb03-dataelement-11519
    Id prsb03-dataelement-11519 (2019‑05‑30 14:36:02)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11296 (2019‑05‑30 12:25:39)
    Description The date and time the record was completed.
    Relationship
    Rationale Composition.date
    Operationalization Date and time.
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Contact details 0 … *
    prsb03-dataelement-11520
    Id prsb03-dataelement-11520 (2019‑05‑30 14:36:02)
    Cardinality 0 … *
    Concept inherits from draft prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
    Description Contact details of the person completing the record.

    Properties

    FHIR PractitionerRole.telecom
    Relationship
    Rationale Practitioner.telecom

    PractitionerRole.telecom

    Organisation.telcom
    Operationalization NHS data dictionary : - UK telephone number
    Value Domain
    Property
    max length
    35
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Legal information 0 … 1
    prsb03-dataelement-520
    Id prsb03-dataelement-520 (2018‑10‑31)
    Cardinality 0 … 1
    Context
    This section identifies where there is legal or formal documentation relating to the care of the person. This includes Lasting Power of Attorney (LPA), Advance Decision to Refuse Treatment (ADRT), Mental Capacity Assessments (MCAs) and Mental Health Act (MHA) status. The documentation may be available centrally as part of shared care records or held locally as part of the persons health and care records. 

    NB: Advance statement element is found in the End of life care section.
    Systems should allow copies of legal documentation to be attached to the record where it would be necessary to see copies of the original documents.

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

    PractitionerRole.telecom

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

    Properties

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

    Properties

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

    Properties

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

    Properties

    FHIR PractitionerRole.telecom
    Relationship
    Rationale Practitioner.telecom

    PractitionerRole.telecom

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

    PractitionerRole.telecom

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

    Properties

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

    Properties

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

    Properties

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

    Properties

    FHIR PractitionerRole.telecom
    Relationship
    Rationale Practitioner.telecom

    PractitionerRole.telecom

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

    PractitionerRole.telecom

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

    Properties

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

    Properties

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

    Properties

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

    Properties

    FHIR PractitionerRole.telecom
    Relationship
    Rationale Practitioner.telecom

    PractitionerRole.telecom

    Organisation.telcom
    Operationalization NHS data dictionary : - UK telephone number
    Value Domain
    Property
    max length
    35
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Mental capacity assessment 0 … *
    prsb03-dataelement-10424
    Id prsb03-dataelement-10424 (2018‑10‑31)
    Cardinality 0 … *
    Description Details of the persons mental capacity assessment
    target Used by one transaction, 0 templates, inherited 2 times
     
    draft Date 0 … 1
    prsb03-dataelement-11688
    Id prsb03-dataelement-11688 (2019‑05‑31 11:50:22)
    Cardinality 0 … 1
    Description The date when the mental capacity assessment was made.
    Operationalization Date and time
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited 3 times
     
    folder draft Location 0 … 1
    prsb03-dataelement-11689
    Id prsb03-dataelement-11689 (2019‑05‑31 11:51:04)
    Cardinality 0 … 1
    Description The location where the mental capacity assessment was made.
    target Used by one transaction, 0 templates, inherited 3 times
     
    draft Coded value 0 … 1
    prsb03-dataelement-13449
    Id prsb03-dataelement-13449 (2020‑08‑27 16:43:20)
    Cardinality 0 … 1
    Description The coded value for location
    Operationalization
    NHS data dictionary : - Organisation code

    Value Domain
    Property
    min length max length
    3 5
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Free text 0 … 1
    prsb03-dataelement-13450
    Id prsb03-dataelement-13450 (2020‑08‑27 16:43:57)
    Cardinality 0 … 1
    Description Free text field to be used if no code is available
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 3 times
     
    draft Mental capacity assessment 0 … 1
    prsb03-dataelement-13724
    Id prsb03-dataelement-13724 (2020‑09‑16 11:32:28)
    Cardinality 0 … 1
    Context
    Mental capacity needs to be assessed at each moment where treatment decisions need to be made. Hence there should be provisions for more than one MCA to be recorded.
    • Mental Capacity Act 2005 (England and Wales)
    • Adults with Incapacity Act 2000 (Scotland)
    • Mental Capacity Act 2016 (Northern Ireland).
    If there is a need to communicate the outcome of a mental capacity assessment it is important to record to which specific decision it relates.

    Description Whether an assessment of the mental capacity of the (adult) person has been undertaken, if so, what capacity the decision relates to and the outcome of the assessment. Also record best interests decision if person lacks capacity.
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Location of document 0 … 1
    prsb03-dataelement-13779
    Id prsb03-dataelement-13779 (2020‑10‑16 16:40:41)
    Cardinality 0 … 1
    Description The location of the mental capacity assessment information.
    Relationship
    Operationalization Free text or URL
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Performing professional 0 … 1
    prsb03-dataelement-11281
    Id prsb03-dataelement-11281 (2019‑05‑30 11:53:30)
    Cardinality 0 … 1
    Description The professional who made the mental capacity assessment.
    target Used by one transaction, 0 templates, inherited 3 times
     
    draft Name 0 … 1
    prsb03-dataelement-11282
    Id prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
    Cardinality 0 … 1
    Description The name of the professional.
    Rationale Practitioner.name
    Operationalization Free text.
    Value Domain
    Property
    max length
    70
    target Used by one transaction, 0 templates, inherited 61 times
     
    draft Role 0 … 1
    prsb03-dataelement-11283
    Id prsb03-dataelement-11283 (2019‑05‑30 11:58:48)
    Cardinality 0 … 1
    Description The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc
    Rationale Practitioner.PractitionerRole.code
    Operationalization FHIR value set :- SDSjobroletype
    Value Domain
    target Used by one transaction, 0 templates, inherited 60 times
     
    draft Grade 0 … 1
    prsb03-dataelement-11288
    Id prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
    Cardinality 0 … 1
    Description The grade of the professional.
    Rationale PractitionerRole.code
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 61 times
     
    draft Speciality 0 … 1
    prsb03-dataelement-11284
    Id prsb03-dataelement-11284 (2019‑05‑30 12:01:15)
    Cardinality 0 … 1
    Description The specialty of the professional e.g. physiotherapy, oncology, mental health etc
    Rationale PractitionerRole.speciality
    Operationalization NHS data dictionary - Activity treatment function code
    Value Domain
    Property
    max length
    3
    target Used by one transaction, 0 templates, inherited 60 times
     
    draft Professional identifier 0 … 1
    prsb03-dataelement-11285
    Id prsb03-dataelement-11285 (2019‑05‑30 12:02:46)
    Cardinality 0 … 1
    Description Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.
    Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
    Operationalization NHS data dictionary : - Professional registration identifier
    Value Domain
    Property
    max length
    32
    target Used by one transaction, 0 templates, inherited 61 times
     
    folder draft Organisation 0 … 1
    prsb03-dataelement-11286
    Id prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
    Cardinality 0 … 1
    Description The name of the organisation the professional works for.
    target Used by one transaction, 0 templates, inherited 61 times
     
    draft Coded value 0 … 1
    prsb03-dataelement-13521
    Id prsb03-dataelement-13521 (2020‑09‑04 13:43:41)
    Cardinality 0 … 1
    Description The coded value for location
    Rationale Practitioner.PractitionerRole.organisation.Name
    Operationalization NHS data dictionary: - Organisation data service
    Value Domain
    Property
    min length max length
    3 7
    target Used by one transaction, 0 templates, inherited once
     
    draft Free text 0 … 1
    prsb03-dataelement-13522
    Id prsb03-dataelement-13522 (2020‑09‑04 13:45:47)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
    Description Free text field to be used if no code is available
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited once
     
    draft Contact details 0 … 1
    prsb03-dataelement-11287
    Id prsb03-dataelement-11287 (2019‑05‑30 12:18:13)
    Cardinality 0 … 1
    Description Contact details of the professional
    Rationale Practitioner.telecom

    PractitionerRole.telecom

    Organisation.telcom
    Operationalization NHS data dictionary - UK phone number
    Value Domain
    Property
    max length
    35
    target Used by one transaction, 0 templates, inherited 61 times
     
    folder draft Person completing record 0 … 1
    prsb03-dataelement-11289
    Id prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
    Cardinality 0 … 1
    Description Details of the person completing the record.
    Relationship
    target Used by one transaction, 0 templates, inherited 68 times
     
    draft Name 0 … 1
    prsb03-dataelement-11290
    Id prsb03-dataelement-11290 (2019‑05‑30 12:25:39)
    Cardinality 0 … 1
    Description The name of the person completing the record.
    Relationship
    Rationale Composition.author.Practitioner.name
    Operationalization Free text.
    Value Domain
    Property
    max length
    70
    target Used by one transaction, 0 templates, inherited 70 times
     
    draft Role 0 … 1
    prsb03-dataelement-11291
    Id prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
    Cardinality 0 … 1
    Description The organisational role of the person completing record.

    Properties

    FHIR PractitionerRole.code of the practitioner completing the record
    Relationship
    Rationale Composition.author.Practitioner.PractitionerRole.code
    Operationalization FHIR value set :- SDSjobrole
    Value Domain
    target Used by one transaction, 0 templates, inherited 70 times
     
    draft Grade 0 … 1
    prsb03-dataelement-11292
    Id prsb03-dataelement-11292 (2019‑05‑30 12:25:39)
    Cardinality 0 … 1
    Description The grade of the person completing the record.
    Relationship
    Rationale PractitionerRole.code
    Operationalization Free text.
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 70 times
     
    draft Specialty 0 … 1
    prsb03-dataelement-11293
    Id prsb03-dataelement-11293 (2019‑05‑30 12:25:39)
    Cardinality 0 … 1
    Description The main specialty of the person completing the record.

    Properties

    FHIR PractitionerRole.specialty
    Relationship
    Rationale PractitionerRole.speciality
    Operationalization NHS data dictionary :- Activity treatment function code
    Value Domain
    Property
    max length
    3
    target Used by one transaction, 0 templates, inherited 70 times
     
    folder draft Organisation 0 … 1
    prsb03-dataelement-11294
    Id prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
    Cardinality 0 … 1
    Description The organisation the person completing the record works for.
    Relationship
    Operationalization NHS data dictionary : - Organisation data service
    target Used by one transaction, 0 templates, inherited 70 times
     
    draft Coded value 0 … 1
    prsb03-dataelement-13523
    Id prsb03-dataelement-13523 (2020‑09‑04 13:52:48)
    Cardinality 0 … 1
    Description The coded value for location
    Rationale Composition.author.Practitioner.PractitionerRole.organisation.Name
    Operationalization NHS data dictionary : - Organisation data service
    Value Domain
    Property
    min length max length
    3 7
    target Used by one transaction, 0 templates, inherited 2 times
     
    draft Free text 0 … 1
    prsb03-dataelement-13524
    Id prsb03-dataelement-13524 (2020‑09‑04 13:54:04)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
    Description Free text field to be used if no code is available
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 2 times
     
    draft Professional identifier 0 … 1
    prsb03-dataelement-11295
    Id prsb03-dataelement-11295 (2019‑05‑30 12:25:39)
    Cardinality 0 … 1
    Description Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.

    Properties

    FHIR PractitionerRole.Practitioner.identifier (local) Practitioner.identifer (professional)
    Relationship
    Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
    Operationalization NHS data dictionary :- Professional registration identifier
    Value Domain
    Property
    max length
    32
    target Used by one transaction, 0 templates, inherited 70 times
     
    draft Date completed 0 … 1
    prsb03-dataelement-11296
    Id prsb03-dataelement-11296 (2019‑05‑30 12:25:39)
    Cardinality 0 … 1
    Description The date and time the record was completed.
    Relationship
    Rationale Composition.date
    Operationalization Date and time.
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited 70 times
     
    draft Contact details 0 … 1
    prsb03-dataelement-11297
    Id prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
    Cardinality 0 … 1
    Description Contact details of the person completing the record.

    Properties

    FHIR PractitionerRole.telecom
    Relationship
    Rationale Practitioner.telecom

    PractitionerRole.telecom

    Organisation.telcom
    Operationalization NHS data dictionary : - UK telephone number
    Value Domain
    Property
    max length
    35
    target Used by one transaction, 0 templates, inherited 70 times
     
    folder draft Lasting power of attorney for health and welfare or court-appointed deputy (or equivalent) 0 … *
    prsb03-dataelement-10425
    Id prsb03-dataelement-10425 (2018‑10‑31)
    Cardinality 0 … *
    Description Details of the person's LPA record or equivalent
    target Used by one transaction, 0 templates, inherited once
     
    draft Date 0 … 1
    prsb03-dataelement-13630
    Id prsb03-dataelement-13630 (2020‑09‑08 20:03:11)
    Cardinality 0 … 1
    Description The date the LPA was recorded
    Operationalization Date and time
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited once
     
    folder draft Location 0 … 1
    prsb03-dataelement-13631
    Id prsb03-dataelement-13631 (2020‑09‑08 20:04:28)
    Cardinality 0 … 1
    Description The location where the LPA was given
    Relationship
    target Used by one transaction, 0 templates, inherited once
     
    draft Coded value 0 … *
    prsb03-dataelement-13632
    Id prsb03-dataelement-13632 (2020‑09‑08 20:05:20)
    Cardinality 0 … *
    Concept inherits from draft prsb03-dataelement-13453 (2020‑08‑27 16:54:58)
    Description The coded value for location
    Operationalization NHS data dictionary : - Organisation code



    Value Domain
    Property
    min length max length
    3 9
    target Used by one transaction, 0 templates, inherited once
     
    draft Free text 0 … 1
    prsb03-dataelement-13633
    Id prsb03-dataelement-13633 (2020‑09‑08 20:05:20)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13454 (2020‑08‑27 16:56:28)
    Description Free text field to be used if no code is available
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited once
     
    folder draft Lasting power of attorney for health and welfare or court appointed deputy (or equivalent) 0 … 1
    prsb03-dataelement-13634
    Id prsb03-dataelement-13634 (2020‑09‑08 20:05:47)
    Cardinality 0 … 1
    Context Lasting power of attorney (LPA)  should include details of one or more people who have been given power by the person when they had capacity to make decisions about their health and welfare should they lose capacity to make those decisions. To be valid, an LPA must have been registered with the Court of Protection. If life- sustaining treatment is being considered the LPA document must state specifically that the attorney has been given power to consent to or refuse life-sustaining treatment.
    Description Record of one or more people who have been given power (LPA) by the person when they had capacity to make decisions about their health and welfare should they lose capacity to make those decisions. To be valid, an LPA must have been registered with the Court of Protection. If life-sustaining treatment is being considered the LPA document must state specifically that the attorney has been given power to consent to or refuse life-sustaining treatment. Details of any person (deputy) appointed by the court to make decisions about the person’s health and welfare. A deputy does not have the power to refuse life-sustaining treatment.
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Coded value 0 … 1
    prsb03-dataelement-13636
    Id prsb03-dataelement-13636 (2020‑09‑08 20:10:08)
    Cardinality 0 … 1
    Description The coded value for the LPA
    Operationalization SNOMED CT: - ^999001951000000107 |Personal welfare lasting power of attorney findings simple reference set (foundation metadata concept)|
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Location of document 0 … 1
    prsb03-dataelement-13776
    Id prsb03-dataelement-13776 (2020‑10‑12 13:50:45)
    Cardinality 0 … 1
    Description The location of the LPA information
    Operationalization Free text or URL
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited once
     
    draft Name of LPA 0 … 1
    prsb03-dataelement-13635
    Id prsb03-dataelement-13635 (2020‑09‑08 20:08:39)
    Cardinality 0 … 1
    Description The names of any appointed people or deputies
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited once
     
    draft Contact details 0 … 1
    prsb03-dataelement-13637
    Id prsb03-dataelement-13637 (2020‑09‑08 20:11:29)
    Cardinality 0 … 1
    Description The contact details of the LPA
    Operationalization NHS data dictionary:- UK telephone number
    Value Domain
    Property
    max length
    35
    target Used by one transaction, 0 templates, inherited once
     
    folder draft Performing professional 0 … 1
    prsb03-dataelement-13638
    Id prsb03-dataelement-13638 (2020‑09‑08 20:13:16)
    Cardinality 0 … 1
    Description The professional who took the details of the LPA or equivalent
    Relationship
    target Used by one transaction, 0 templates, inherited once
     
    draft Name 0 … 1
    prsb03-dataelement-13639
    Id prsb03-dataelement-13639 (2020‑09‑08 20:13:55)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13463 (2020‑09‑02 12:38:25)
    Description The name of the professional.
    Rationale Practitioner.name
    Operationalization Free text.
    Value Domain
    Property
    max length
    70
    target Used by one transaction, 0 templates, inherited once
     
    draft Role 0 … 1
    prsb03-dataelement-13640
    Id prsb03-dataelement-13640 (2020‑09‑08 20:13:55)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13464 (2020‑09‑02 12:38:25)
    Description The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc
    Rationale Practitioner.PractitionerRole.code
    Operationalization FHIR value set :- SDSjobroletype
    Value Domain
    target Used by one transaction, 0 templates, inherited once
     
    draft Grade 0 … 1
    prsb03-dataelement-13641
    Id prsb03-dataelement-13641 (2020‑09‑08 20:13:55)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13465 (2020‑09‑02 12:38:25)
    Description The grade of the professional.
    Rationale PractitionerRole.code
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited once
     
    draft Speciality 0 … 1
    prsb03-dataelement-13642
    Id prsb03-dataelement-13642 (2020‑09‑08 20:13:55)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13466 (2020‑09‑02 12:38:25)
    Description The specialty of the professional e.g. physiotherapy, oncology, mental health etc
    Rationale PractitionerRole.speciality
    Operationalization NHS data dictionary - Activity treatment function code
    Value Domain
    Property
    max length
    3
    target Used by one transaction, 0 templates, inherited once
     
    draft Professional identifier 0 … 1
    prsb03-dataelement-13643
    Id prsb03-dataelement-13643 (2020‑09‑08 20:13:55)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13467 (2020‑09‑02 12:38:25)
    Description Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.
    Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
    Operationalization NHS data dictionary : - Professional registration identifier
    Value Domain
    Property
    max length
    32
    target Used by one transaction, 0 templates, inherited once
     
    folder draft Organisation 0 … 1
    prsb03-dataelement-13644
    Id prsb03-dataelement-13644 (2020‑09‑08 20:13:55)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13468 (2020‑09‑02 12:38:25)
    Description The name of the organisation the professional works for.
    target Used by one transaction, 0 templates, inherited once
     
    draft Contact details 0 … 1
    prsb03-dataelement-13645
    Id prsb03-dataelement-13645 (2020‑09‑08 20:13:55)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13469 (2020‑09‑02 12:38:25)
    Description Contact details of the professional
    Rationale Practitioner.telecom

    PractitionerRole.telecom

    Organisation.telcom
    Operationalization NHS data dictionary - UK phone number
    Value Domain
    Property
    max length
    35
    target Used by one transaction, 0 templates, inherited once
     
    folder draft Person completing record 0 … 1
    prsb03-dataelement-13646
    Id prsb03-dataelement-13646 (2020‑09‑08 20:14:17)
    Cardinality 0 … 1
    Description Details of the person who took the LPA.
    Relationship
    target Used by one transaction, 0 templates, inherited once
     
    draft Name 0 … 1
    prsb03-dataelement-13647
    Id prsb03-dataelement-13647 (2020‑09‑08 20:14:49)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13493 (2020‑09‑02 17:10:59)
    Description The name of the person completing the record.
    Relationship
    Rationale Composition.author.Practitioner.name
    Operationalization Free text.
    Value Domain
    Property
    max length
    70
    target Used by one transaction, 0 templates, inherited once
     
    draft Role 0 … 1
    prsb03-dataelement-13648
    Id prsb03-dataelement-13648 (2020‑09‑08 20:14:49)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13494 (2020‑09‑02 17:10:59)
    Description The organisational role of the person completing record.

    Properties

    FHIR PractitionerRole.code of the practitioner completing the record
    Relationship
    Rationale Composition.author.Practitioner.PractitionerRole.code
    Operationalization FHIR value set :- SDSjobrole
    Value Domain
    target Used by one transaction, 0 templates, inherited once
     
    draft Grade 0 … 1
    prsb03-dataelement-13649
    Id prsb03-dataelement-13649 (2020‑09‑08 20:14:49)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13495 (2020‑09‑02 17:10:59)
    Description The grade of the person completing the record.
    Relationship
    Rationale PractitionerRole.code
    Operationalization Free text.
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited once
     
    draft Specialty 0 … 1
    prsb03-dataelement-13650
    Id prsb03-dataelement-13650 (2020‑09‑08 20:14:49)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13496 (2020‑09‑02 17:10:59)
    Description The main specialty of the person completing the record.

    Properties

    FHIR PractitionerRole.specialty
    Relationship
    Rationale PractitionerRole.speciality
    Operationalization NHS data dictionary :- Activity treatment function code
    Value Domain
    Property
    max length
    3
    target Used by one transaction, 0 templates, inherited once
     
    folder draft Organisation 0 … 1
    prsb03-dataelement-13651
    Id prsb03-dataelement-13651 (2020‑09‑08 20:14:49)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13497 (2020‑09‑02 17:10:59)
    Description The organisation the person completing the record works for.
    Relationship
    Operationalization NHS data dictionary : - Organisation data service
    target Used by one transaction, 0 templates, inherited once
     
    draft Professional identifier 0 … 1
    prsb03-dataelement-13652
    Id prsb03-dataelement-13652 (2020‑09‑08 20:14:49)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13498 (2020‑09‑02 17:10:59)
    Description Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.

    Properties

    FHIR PractitionerRole.Practitioner.identifier (local) Practitioner.identifer (professional)
    Relationship
    Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
    Operationalization NHS data dictionary :- Professional registration identifier
    Value Domain
    Property
    max length
    32
    target Used by one transaction, 0 templates, inherited once
     
    draft Date completed 0 … 1
    prsb03-dataelement-13653
    Id prsb03-dataelement-13653 (2020‑09‑08 20:14:49)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13499 (2020‑09‑02 17:10:59)
    Description The date and time the record was completed.
    Relationship
    Rationale Composition.date
    Operationalization Date and time.
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited once
     
    draft Contact details 0 … 1
    prsb03-dataelement-13654
    Id prsb03-dataelement-13654 (2020‑09‑08 20:14:49)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13500 (2020‑09‑02 17:10:59)
    Description Contact details of the person completing the record.

    Properties

    FHIR PractitionerRole.telecom
    Relationship
    Rationale Practitioner.telecom

    PractitionerRole.telecom

    Organisation.telcom
    Operationalization NHS data dictionary : - UK telephone number
    Value Domain
    Property
    max length
    35
    target Used by one transaction, 0 templates, inherited once
     
    folder draft Advance decision to refuse treatment (ADRT) 0 … 1
    prsb03-dataelement-10428
    Id prsb03-dataelement-10428 (2018‑10‑31)
    Cardinality 0 … 1
    Description Details of the person's ADRT status.
    target Used by one transaction, 0 templates, inherited once
     
    draft Date 0 … 1
    prsb03-dataelement-13479
    Id prsb03-dataelement-13479 (2020‑09‑02 16:59:59)
    Cardinality 0 … 1
    Description The date the ADRT was recorded.
    Operationalization Date
    Value Domain
    Property
    Timestamp precision
    at least day, month and year
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Location 0 … 1
    prsb03-dataelement-13480
    Id prsb03-dataelement-13480 (2020‑09‑02 17:01:08)
    Cardinality 0 … 1
    Description The location where the ADRT was recorded.
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Coded value 0 … 1
    prsb03-dataelement-13481
    Id prsb03-dataelement-13481 (2020‑09‑02 17:01:48)
    Cardinality 0 … 1
    Description The coded value of location
    Operationalization NHS data dictionary : - Organisation data service
    Value Domain
    Property
    min length max length
    3 5
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Free text 0 … 1
    prsb03-dataelement-13482
    Id prsb03-dataelement-13482 (2020‑09‑02 17:03:31)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13223 (2020‑07‑08 17:40:09)
    Description Free text field to be used if no coded text available
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Advance decision to refuse treatment 0 … 1
    prsb03-dataelement-13502
    Id prsb03-dataelement-13502 (2020‑09‑02 17:36:30)
    Cardinality 0 … 1
    Description A record of an advance decision to refuse one or more specific types of future treatment, made by a person who had capacity at the time of recording the decision. The decision only applies when the person no longer has the capacity to consent to or refuse the specific treatment being considered. An ADRT must be in writing, signed and witnessed. If the ADRT is refusing life-sustaining treatment it must state specifically that the treatment is refused even if the person’s life is at risk.
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Coded value 0 … 1
    prsb03-dataelement-13503
    Id prsb03-dataelement-13503 (2020‑09‑02 17:46:53)
    Cardinality 0 … 1
    Description The coded value for advance decision to refuse treatment.
    Operationalization SNOMED CT:- ^ 999002181000000105 |Advance decision to refuse treatment preference findings simple reference set (foundation metadata concept)|
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Free text 0 … 1
    prsb03-dataelement-13504
    Id prsb03-dataelement-13504 (2020‑09‑02 17:48:38)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
    Description Free text field to be used if no code is available
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Performing professional 0 … 1
    prsb03-dataelement-13484
    Id prsb03-dataelement-13484 (2020‑09‑02 17:08:08)
    Cardinality 0 … 1
    Description The professional who recorded the ADRT
    Relationship
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Name 0 … 1
    prsb03-dataelement-13485
    Id prsb03-dataelement-13485 (2020‑09‑02 17:08:45)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13463 (2020‑09‑02 12:38:25)
    Description The name of the professional.
    Rationale Practitioner.name
    Operationalization Free text.
    Value Domain
    Property
    max length
    70
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Role 0 … 1
    prsb03-dataelement-13486
    Id prsb03-dataelement-13486 (2020‑09‑02 17:08:45)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13464 (2020‑09‑02 12:38:25)
    Description The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc
    Rationale Practitioner.PractitionerRole.code
    Operationalization FHIR value set :- SDSjobroletype
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Grade 0 … 1
    prsb03-dataelement-13487
    Id prsb03-dataelement-13487 (2020‑09‑02 17:08:45)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13465 (2020‑09‑02 12:38:25)
    Description The grade of the professional.
    Rationale PractitionerRole.code
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Speciality 0 … 1
    prsb03-dataelement-13488
    Id prsb03-dataelement-13488 (2020‑09‑02 17:08:45)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13466 (2020‑09‑02 12:38:25)
    Description The specialty of the professional e.g. physiotherapy, oncology, mental health etc
    Rationale PractitionerRole.speciality
    Operationalization NHS data dictionary - Activity treatment function code
    Value Domain
    Property
    max length
    3
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Professional identifier 0 … 1
    prsb03-dataelement-13489
    Id prsb03-dataelement-13489 (2020‑09‑02 17:08:45)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13467 (2020‑09‑02 12:38:25)
    Description Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.
    Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
    Operationalization NHS data dictionary : - Professional registration identifier
    Value Domain
    Property
    max length
    32
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Organisation 0 … 1
    prsb03-dataelement-13490
    Id prsb03-dataelement-13490 (2020‑09‑02 17:08:45)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13468 (2020‑09‑02 12:38:25)
    Description The name of the organisation the professional works for.
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Contact details 0 … 1
    prsb03-dataelement-13491
    Id prsb03-dataelement-13491 (2020‑09‑02 17:08:45)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13469 (2020‑09‑02 12:38:25)
    Description Contact details of the professional
    Rationale Practitioner.telecom

    PractitionerRole.telecom

    Organisation.telcom
    Operationalization NHS data dictionary - UK phone number
    Value Domain
    Property
    max length
    35
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Person completing record 0 … 1
    prsb03-dataelement-13492
    Id prsb03-dataelement-13492 (2020‑09‑02 17:10:28)
    Cardinality 0 … 1
    Description Details of the person who recorded the ADRT.
    Relationship
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Name 0 … 1
    prsb03-dataelement-13493
    Id prsb03-dataelement-13493 (2020‑09‑02 17:10:59)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13053 (2020‑04‑28 19:36:38)
    Description The name of the person completing the record.
    Relationship
    Rationale Composition.author.Practitioner.name
    Operationalization Free text.
    Value Domain
    Property
    max length
    70
    target Used by one transaction, 0 templates, inherited once
     
    draft Role 0 … 1
    prsb03-dataelement-13494
    Id prsb03-dataelement-13494 (2020‑09‑02 17:10:59)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13054 (2020‑04‑28 19:36:38)
    Description The organisational role of the person completing record.

    Properties

    FHIR PractitionerRole.code of the practitioner completing the record
    Relationship
    Rationale Composition.author.Practitioner.PractitionerRole.code
    Operationalization FHIR value set :- SDSjobrole
    Value Domain
    target Used by one transaction, 0 templates, inherited once
     
    draft Grade 0 … 1
    prsb03-dataelement-13495
    Id prsb03-dataelement-13495 (2020‑09‑02 17:10:59)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13055 (2020‑04‑28 19:36:38)
    Description The grade of the person completing the record.
    Relationship
    Rationale PractitionerRole.code
    Operationalization Free text.
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited once
     
    draft Specialty 0 … 1
    prsb03-dataelement-13496
    Id prsb03-dataelement-13496 (2020‑09‑02 17:10:59)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13056 (2020‑04‑28 19:36:38)
    Description The main specialty of the person completing the record.

    Properties

    FHIR PractitionerRole.specialty
    Relationship
    Rationale PractitionerRole.speciality
    Operationalization NHS data dictionary :- Activity treatment function code
    Value Domain
    Property
    max length
    3
    target Used by one transaction, 0 templates, inherited once
     
    folder draft Organisation 0 … 1
    prsb03-dataelement-13497
    Id prsb03-dataelement-13497 (2020‑09‑02 17:10:59)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13057 (2020‑04‑28 19:36:38)
    Description The organisation the person completing the record works for.
    Relationship
    Operationalization NHS data dictionary : - Organisation data service
    target Used by one transaction, 0 templates, inherited once
     
    draft Professional identifier 0 … 1
    prsb03-dataelement-13498
    Id prsb03-dataelement-13498 (2020‑09‑02 17:10:59)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13058 (2020‑04‑28 19:36:38)
    Description Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.

    Properties

    FHIR PractitionerRole.Practitioner.identifier (local) Practitioner.identifer (professional)
    Relationship
    Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
    Operationalization NHS data dictionary :- Professional registration identifier
    Value Domain
    Property
    max length
    32
    target Used by one transaction, 0 templates, inherited once
     
    draft Date completed 0 … 1
    prsb03-dataelement-13499
    Id prsb03-dataelement-13499 (2020‑09‑02 17:10:59)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13059 (2020‑04‑28 19:36:38)
    Description The date and time the record was completed.
    Relationship
    Rationale Composition.date
    Operationalization Date and time.
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited once
     
    draft Contact details 0 … 1
    prsb03-dataelement-13500
    Id prsb03-dataelement-13500 (2020‑09‑02 17:10:59)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13060 (2020‑04‑28 19:36:38)
    Description Contact details of the person completing the record.

    Properties

    FHIR PractitionerRole.telecom
    Relationship
    Rationale Practitioner.telecom

    PractitionerRole.telecom

    Organisation.telcom
    Operationalization NHS data dictionary : - UK telephone number
    Value Domain
    Property
    max length
    35
    target Used by one transaction, 0 templates, inherited once
     
    folder draft Safeguarding 0 … 1
    prsb03-dataelement-271
    Id prsb03-dataelement-271 (2018‑10‑31)
    Cardinality 0 … 1
    Description The safeguarding details of the person.
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Safeguarding concerns 0 … 1
    prsb03-dataelement-10821
    Id prsb03-dataelement-10821 (2019‑03‑21 12:14:49)
    Cardinality 0 … 1
    Description Details of safeguarding concerns
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Safeguarding indicator 0 … 1
    prsb03-dataelement-13428
    Id prsb03-dataelement-13428 (2020‑08‑12 15:01:11) 0.1
    Cardinality 0 … 1
    Description Indicates whether or not the hospital considers that there are safeguarding issues associated with the patient.
    Operationalization Flag: No =N: Yes = Y
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Safeguarding concerns date 0 … 1
    prsb03-dataelement-10172
    Id prsb03-dataelement-10172 (2018‑10‑31)
    Cardinality 0 … 1
    Description The date the safeguarding concerns were identified.
    Operationalization Date and time
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Safeguarding concerns end date 0 … 1
    prsb03-dataelement-10766
    Id prsb03-dataelement-10766 (2019‑03‑18 17:51:29)
    Cardinality 0 … 1
    Description The date safeguarding concerns ended.
    Operationalization Date and time
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Location 0 … 1
    prsb03-dataelement-10173
    Id prsb03-dataelement-10173 (2018‑10‑31)
    Cardinality 0 … 1
    Description The location where the safeguarding concerns were identified.
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Coded value 0 … 1
    prsb03-dataelement-13437
    Id prsb03-dataelement-13437 (2020‑08‑14 15:30:27)
    Cardinality 0 … 1
    Description The coded value of location
    Operationalization NHS data dictionary : - Organisation code

    Value Domain
    Property
    min length max length
    3 9
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Free text 0 … 1
    prsb03-dataelement-13438
    Id prsb03-dataelement-13438 (2020‑08‑14 15:32:13)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
    Description Free text field to be used if no code is available
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Safeguarding concerns 0 … 1
    prsb03-dataelement-10171
    Id prsb03-dataelement-10171 (2018‑10‑31)
    Cardinality 0 … 1
    Description Identified safeguarding concerns.

    Properties

    FHIR Composition.text
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Coded value 0 … 1
    prsb03-dataelement-13756
    Id prsb03-dataelement-13756 (2020‑09‑29 12:22:26)
    Cardinality 0 … 1
    Description The coded value for safeguarding concerns
    Operationalization SNOMED CT : - ^999002381000000108 | Safeguarding issues simple reference set (foundation metadata concept) |
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Free text 0 … 1
    prsb03-dataelement-13757
    Id prsb03-dataelement-13757 (2020‑09‑29 12:23:18)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
    Description Free text field to be used if no code is available
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Performing professional 0 … 1
    prsb03-dataelement-11358
    Id prsb03-dataelement-11358 (2019‑05‑30 13:51:50)
    Cardinality 0 … 1
    Description The professional who identified the safeguarding concerns.
    Relationship
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Name 0 … 1
    prsb03-dataelement-11359
    Id prsb03-dataelement-11359 (2019‑05‑30 13:52:16)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
    Description The name of the professional.
    Rationale Practitioner.name
    Operationalization Free text.
    Value Domain
    Property
    max length
    70
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Role 0 … 1
    prsb03-dataelement-11360
    Id prsb03-dataelement-11360 (2019‑05‑30 13:52:16)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11283 (2019‑05‑30 11:58:48)
    Description The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc
    Rationale Practitioner.PractitionerRole.code
    Operationalization FHIR value set :- SDSjobroletype
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Grade 0 … 1
    prsb03-dataelement-11361
    Id prsb03-dataelement-11361 (2019‑05‑30 13:52:16)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
    Description The grade of the professional.
    Rationale PractitionerRole.code
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Speciality 0 … 1
    prsb03-dataelement-11362
    Id prsb03-dataelement-11362 (2019‑05‑30 13:52:16)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11284 (2019‑05‑30 12:01:15)
    Description The specialty of the professional e.g. physiotherapy, oncology, mental health etc
    Rationale PractitionerRole.speciality
    Operationalization NHS data dictionary - Activity treatment function code
    Value Domain
    Property
    max length
    3
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Professional identifier 0 … 1
    prsb03-dataelement-11363
    Id prsb03-dataelement-11363 (2019‑05‑30 13:52:16)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11285 (2019‑05‑30 12:02:46)
    Description Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.
    Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
    Operationalization NHS data dictionary : - Professional registration identifier
    Value Domain
    Property
    max length
    32
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Organisation 0 … 1
    prsb03-dataelement-11364
    Id prsb03-dataelement-11364 (2019‑05‑30 13:52:16)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
    Description The name of the organisation the professional works for.
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Contact details 0 … 1
    prsb03-dataelement-11365
    Id prsb03-dataelement-11365 (2019‑05‑30 13:52:16)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11287 (2019‑05‑30 12:18:13)
    Description Contact details of the professional
    Rationale Practitioner.telecom

    PractitionerRole.telecom

    Organisation.telcom
    Operationalization NHS data dictionary - UK phone number
    Value Domain
    Property
    max length
    35
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Person completing record 0 … 1
    prsb03-dataelement-11366
    Id prsb03-dataelement-11366 (2019‑05‑30 13:53:06)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
    Description Details of the person completing the record.
    Relationship
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Name 0 … 1
    prsb03-dataelement-11367
    Id prsb03-dataelement-11367 (2019‑05‑30 13:53:34)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11290 (2019‑05‑30 12:25:39)
    Description The name of the person completing the record.
    Relationship
    Rationale Composition.author.Practitioner.name
    Operationalization Free text.
    Value Domain
    Property
    max length
    70
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Role 0 … 1
    prsb03-dataelement-11368
    Id prsb03-dataelement-11368 (2019‑05‑30 13:53:34)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
    Description The organisational role of the person completing record.

    Properties

    FHIR PractitionerRole.code of the practitioner completing the record
    Relationship
    Rationale Composition.author.Practitioner.PractitionerRole.code
    Operationalization FHIR value set :- SDSjobrole
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Grade 0 … 1
    prsb03-dataelement-11369
    Id prsb03-dataelement-11369 (2019‑05‑30 13:53:34)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11292 (2019‑05‑30 12:25:39)
    Description The grade of the person completing the record.
    Relationship
    Rationale PractitionerRole.code
    Operationalization Free text.
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Specialty 0 … 1
    prsb03-dataelement-11370
    Id prsb03-dataelement-11370 (2019‑05‑30 13:53:34)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11293 (2019‑05‑30 12:25:39)
    Description The main specialty of the person completing the record.

    Properties

    FHIR PractitionerRole.specialty
    Relationship
    Rationale PractitionerRole.speciality
    Operationalization NHS data dictionary :- Activity treatment function code
    Value Domain
    Property
    max length
    3
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Organisation 0 … 1
    prsb03-dataelement-11371
    Id prsb03-dataelement-11371 (2019‑05‑30 13:53:34)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
    Description The organisation the person completing the record works for.
    Relationship
    Operationalization NHS data dictionary : - Organisation data service
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Professional identifier 0 … 1
    prsb03-dataelement-11372
    Id prsb03-dataelement-11372 (2019‑05‑30 13:53:34)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11295 (2019‑05‑30 12:25:39)
    Description Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.

    Properties

    FHIR PractitionerRole.Practitioner.identifier (local) Practitioner.identifer (professional)
    Relationship
    Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
    Operationalization NHS data dictionary :- Professional registration identifier
    Value Domain
    Property
    max length
    32
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Date completed 0 … 1
    prsb03-dataelement-11373
    Id prsb03-dataelement-11373 (2019‑05‑30 13:53:34)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11296 (2019‑05‑30 12:25:39)
    Description The date and time the record was completed.
    Relationship
    Rationale Composition.date
    Operationalization Date and time.
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Contact details 0 … 1
    prsb03-dataelement-11374
    Id prsb03-dataelement-11374 (2019‑05‑30 13:53:34)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
    Description Contact details of the person completing the record.

    Properties

    FHIR PractitionerRole.telecom
    Relationship
    Rationale Practitioner.telecom

    PractitionerRole.telecom

    Organisation.telcom
    Operationalization NHS data dictionary : - UK telephone number
    Value Domain
    Property
    max length
    35
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Comment 0 … 1
    prsb03-dataelement-10175
    Id prsb03-dataelement-10175 (2018‑10‑31)
    Cardinality 0 … 1
    Description Further details on safeguarding concerns.
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Professional contacts 0 … 1
    prsb03-dataelement-452
    Id prsb03-dataelement-452 (2018‑10‑31)
    Cardinality 0 … 1
    Description The details of the person’s professional contacts.
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Professional contacts record entry 0 … *
    prsb03-dataelement-10767
    Id prsb03-dataelement-10767 (2019‑03‑18 18:07:16)
    Cardinality 0 … *
    Description This is a professional contacts record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
    target Used by one transaction, 0 templates, inherited 2 times
     
    draft Name 0 … 1
    prsb03-dataelement-10352
    Id prsb03-dataelement-10352 (2018‑10‑31)
    Cardinality 0 … 1
    Description The name of the professional with responsibility for the care of the person.
    Operationalization Free text
    Value Domain
    Property
    max length
    70
    target Used by one transaction, 0 templates, inherited 6 times
     
    draft Role 0 … 1
    prsb03-dataelement-10353
    Id prsb03-dataelement-10353 (2018‑10‑31)
    Cardinality 0 … 1
    Description 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) etc
    Operationalization FHIR value set : - SDSjobrole
    Value Domain
    target Used by one transaction, 0 templates, inherited 6 times
     
    draft Key worker 0 … 1
    prsb03-dataelement-12973
    Id prsb03-dataelement-12973 (2020‑04‑06 20:02:00)
    Cardinality 0 … 1
    Description A flag that identifies the personal contact is the key worker assigned to the person.
    Operationalization Flag : - Yes or No
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Speciality 0 … 1
    prsb03-dataelement-10354
    Id prsb03-dataelement-10354 (2018‑10‑31)
    Cardinality 0 … 1
    Description The specialty of the professional e.g. physiotherapy, oncology, mental health etc
    Operationalization NHS data dictionary : - Activity treatment function code
    Value Domain
    Property
    max length
    3
    target Used by one transaction, 0 templates, inherited 2 times
     
    draft Team 0 … 1
    prsb03-dataelement-10355
    Id prsb03-dataelement-10355 (2018‑10‑31)
    Cardinality 0 … 1
    Description The name of the team.
    Operationalization Free text
    Value Domain
    Property
    max length
    35
    target Used by one transaction, 0 templates, inherited 3 times
     
    folder draft Organisation 0 … 1
    prsb03-dataelement-10356
    Id prsb03-dataelement-10356 (2018‑10‑31)
    Cardinality 0 … 1
    Description The name of the organisation.
    target Used by one transaction, 0 templates, inherited 2 times
     
    draft Coded value 0 … 1
    prsb03-dataelement-13564
    Id prsb03-dataelement-13564 (2020‑09‑04 18:18:34)
    Cardinality 0 … 1
    Description The coded value for location
    Operationalization NHS data dictionary : - Organisation data service
    Value Domain
    Property
    min length max length
    3 5
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Free text 0 … 1
    prsb03-dataelement-13565
    Id prsb03-dataelement-13565 (2020‑09‑04 18:19:37)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
    Description Free text field to be used if no code is available
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Contact details 0 … 1
    prsb03-dataelement-10357
    Id prsb03-dataelement-10357 (2018‑10‑31)
    Cardinality 0 … 1
    Description Contact details of the professional (e.g. telephone number, email address etc.).
    Operationalization Free text
    Value Domain
    Property
    max length
    35
    target Used by one transaction, 0 templates, inherited 6 times
     
    draft Start date 0 … 1
    prsb03-dataelement-10358
    Id prsb03-dataelement-10358 (2018‑10‑31)
    Cardinality 0 … 1
    Description The start date of the professional relationship with the person.
    Operationalization Date and time
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited 2 times
     
    draft End date 0 … 1
    prsb03-dataelement-10359
    Id prsb03-dataelement-10359 (2018‑10‑31)
    Cardinality 0 … 1
    Description The end date of the professional relationship with the person.
    Operationalization Date and time
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited 2 times
     
    folder draft Personal contacts 0 … 1
    prsb03-dataelement-445
    Id prsb03-dataelement-445 (2018‑10‑31)
    Cardinality 0 … 1
    Description The details of the individual's personal contacts.
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Personal contacts record entry 0 … *
    prsb03-dataelement-10768
    Id prsb03-dataelement-10768 (2019‑03‑19 13:05:13)
    Cardinality 0 … *
    Description This is personal contacts record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Name 0 … 1
    prsb03-dataelement-10345
    Id prsb03-dataelement-10345 (2018‑10‑31)
    Cardinality 0 … 1
    Description The name of the personal contact.
    Operationalization Free text
    Value Domain
    Property
    max length
    70
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Relationship 0 … 1
    prsb03-dataelement-10346
    Id prsb03-dataelement-10346 (2018‑10‑31)
    Cardinality 0 … 1
    Description The relationship the personal contact has to the person, e.g. father, grandmother, family friend etc.
    Operationalization FHIR value set : - Related person
    Value Domain
    Property
    default
    10
    target Used by one transaction, 0 templates, inherited 3 times
     
    draft Relationship type 0 … 1
    prsb03-dataelement-12968
    Id prsb03-dataelement-12968 (2020‑04‑06 13:13:10)
    Cardinality 0 … 1
    Description Additional roles the person performs on behalf of the other (e.g. Carer, Next of Kin, Emergency Contact, Dependent, etc.)
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Parental Responsibility 0 … 1
    prsb03-dataelement-10347
    Id prsb03-dataelement-10347 (2018‑10‑31)
    Cardinality 0 … 1
    Description Flag to indicate whether the personal contact has parental responsibility
    Operationalization Flag ; - Yes or No
    Value Domain
    Property
    max length
    3
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Household member 0 … 1
    prsb03-dataelement-10348
    Id prsb03-dataelement-10348 (2018‑10‑31)
    Cardinality 0 … 1
    Description Status identifying whether the personal contact is a member of the same household
    Operationalization Flag : - Yes or No
    Value Domain
    Property
    max length
    3
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Contact details 0 … 1
    prsb03-dataelement-10350
    Id prsb03-dataelement-10350 (2018‑10‑31)
    Cardinality 0 … 1
    Description Contact details of the personal contact (e.g. telephone number, email address etc.)
    Operationalization Free Text
    Value Domain
    Property
    max length
    70
    target Used by one transaction, 0 templates, inherited once
     
    draft Comments 0 … 1
    prsb03-dataelement-10937
    Id prsb03-dataelement-10937 (2019‑05‑02 17:15:44)
    Cardinality 0 … 1
    Description Notes on the significance of the personal contact to the person.
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Participation in research 0 … 1
    prsb03-dataelement-168
    Id prsb03-dataelement-168 (2018‑10‑31)
    Cardinality 0 … 1
    Description Participation in research
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Participation in research record entry 0 … *
    prsb03-dataelement-10646
    Id prsb03-dataelement-10646 (2018‑11‑12 15:14:45)
    Cardinality 0 … *
    Description This is a Participation in research record entry. There may be 0 to many record entry/entries under a section. Each record entry is made up of a number of elements or data items.
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Name of research study 0 … 1
    prsb03-dataelement-10068
    Id prsb03-dataelement-10068 (2018‑10‑31)
    Cardinality 0 … 1
    Description Name and details of the research study/trial and/or drug/intervention
    Operationalization Free text or URL
    Value Domain
    Property
    max length
    250
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Identification code 0 … 1
    prsb03-dataelement-10739
    Id prsb03-dataelement-10739 (2019‑02‑12 17:27:10)
    Cardinality 0 … 1
    Description Identification code of research study
    Operationalization NHS data dictionary :- Clinical trial identifier
    Value Domain
    Property
    max length
    20
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Person completing record 0 … 1
    prsb03-dataelement-12201
    Id prsb03-dataelement-12201 (2019‑05‑31 16:24:08)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
    Description Details of the person completing the record.
    Relationship
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Name 0 … 1
    prsb03-dataelement-12202
    Id prsb03-dataelement-12202 (2019‑05‑31 16:24:35)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11290 (2019‑05‑30 12:25:39)
    Description The name of the person completing the record.
    Relationship
    Rationale Composition.author.Practitioner.name
    Operationalization Free text.
    Value Domain
    Property
    max length
    70
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Role 0 … 1
    prsb03-dataelement-12203
    Id prsb03-dataelement-12203 (2019‑05‑31 16:24:35)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
    Description The organisational role of the person completing record.

    Properties

    FHIR PractitionerRole.code of the practitioner completing the record
    Relationship
    Rationale Composition.author.Practitioner.PractitionerRole.code
    Operationalization FHIR value set :- SDSjobrole
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Grade 0 … 1
    prsb03-dataelement-12204
    Id prsb03-dataelement-12204 (2019‑05‑31 16:24:35)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11292 (2019‑05‑30 12:25:39)
    Description The grade of the person completing the record.
    Relationship
    Rationale PractitionerRole.code
    Operationalization Free text.
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Specialty 0 … 1
    prsb03-dataelement-12205
    Id prsb03-dataelement-12205 (2019‑05‑31 16:24:35)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11293 (2019‑05‑30 12:25:39)
    Description The main specialty of the person completing the record.

    Properties

    FHIR PractitionerRole.specialty
    Relationship
    Rationale PractitionerRole.speciality
    Operationalization NHS data dictionary :- Activity treatment function code
    Value Domain
    Property
    max length
    3
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Organisation 0 … 1
    prsb03-dataelement-12206
    Id prsb03-dataelement-12206 (2019‑05‑31 16:24:35)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
    Description The organisation the person completing the record works for.
    Relationship
    Operationalization NHS data dictionary : - Organisation data service
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Professional identifier 0 … 1
    prsb03-dataelement-12207
    Id prsb03-dataelement-12207 (2019‑05‑31 16:24:35)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11295 (2019‑05‑30 12:25:39)
    Description Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.

    Properties

    FHIR PractitionerRole.Practitioner.identifier (local) Practitioner.identifer (professional)
    Relationship
    Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
    Operationalization NHS data dictionary :- Professional registration identifier
    Value Domain
    Property
    max length
    32
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Date completed 0 … 1
    prsb03-dataelement-12208
    Id prsb03-dataelement-12208 (2019‑05‑31 16:24:35)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11296 (2019‑05‑30 12:25:39)
    Description The date and time the record was completed.
    Relationship
    Rationale Composition.date
    Operationalization Date and time.
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Contact details 0 … 1
    prsb03-dataelement-12209
    Id prsb03-dataelement-12209 (2019‑05‑31 16:24:35)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
    Description Contact details of the person completing the record.

    Properties

    FHIR PractitionerRole.telecom
    Relationship
    Rationale Practitioner.telecom

    PractitionerRole.telecom

    Organisation.telcom
    Operationalization NHS data dictionary : - UK telephone number
    Value Domain
    Property
    max length
    35
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Referral details 0 … 1
    prsb03-dataelement-105
    Id prsb03-dataelement-105 (2018‑10‑31)
    Cardinality 0 … 1
    Description The details of the referral.
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Referral details record entry 0 … *
    prsb03-dataelement-10917
    Id prsb03-dataelement-10917 (2019‑04‑09 15:59:55)
    Cardinality 0 … *
    Description This is the referral details record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Date 0 … 1
    prsb03-dataelement-10006
    Id prsb03-dataelement-10006 (2018‑10‑31)
    Cardinality 0 … 1
    Description The date of referral
    Operationalization Date and time
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Referrer details 0 … 1
    prsb03-dataelement-10005
    Id prsb03-dataelement-10005 (2018‑10‑31)
    Cardinality 0 … 1
    Context Referral details should be copied forward from the referral or transfer of care where possible. Coded text ‘self-referral’ should be used where the patient is not referred or transferred from a health/care organisation. Where ‘self-referral’ is recorded the referrer data items should be left blank.
    Description 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.

    Properties

    FHIR Encounter.incomingreferral
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Name 0 … 1
    prsb03-dataelement-10971
    Id prsb03-dataelement-10971 (2019‑05‑22 16:29:39)
    Cardinality 0 … 1
    Description The name of the referrer.
    Operationalization Free text
    Value Domain
    Property
    max length
    70
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Role 0 … 1
    prsb03-dataelement-10972
    Id prsb03-dataelement-10972 (2019‑05‑22 16:30:25)
    Cardinality 0 … 1
    Description Role of the referrer.
    Operationalization FHIR value set : - sdsjobrole
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Grade 0 … 1
    prsb03-dataelement-10973
    Id prsb03-dataelement-10973 (2019‑05‑22 16:31:10)
    Cardinality 0 … 1
    Description The grade of the referrer.
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Team 0 … 1
    prsb03-dataelement-12409
    Id prsb03-dataelement-12409 (2019‑06‑05 18:11:50)
    Cardinality 0 … 1
    Description The team or department of the referrer.
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Specialty 0 … 1
    prsb03-dataelement-12410
    Id prsb03-dataelement-12410 (2019‑06‑05 18:12:15)
    Cardinality 0 … 1
    Description The specialty of the referrer.
    Operationalization NHS data dictionary - Activity treatment function code
    Value Domain
    Property
    max length
    3
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Service 0 … 1
    prsb03-dataelement-12411
    Id prsb03-dataelement-12411 (2019‑06‑05 18:20:01)
    Cardinality 0 … 1
    Description The service of the referrer.
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Coded value 0 … 1
    prsb03-dataelement-13397
    Id prsb03-dataelement-13397 (2020‑08‑10 19:10:14)
    Cardinality 0 … 1
    Description The coded value for service
    Operationalization SNOMED CT: - 1127531000000102 |Services simple reference set (foundation metadata concept)|
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Free text 0 … 1
    prsb03-dataelement-13398
    Id prsb03-dataelement-13398 (2020‑08‑10 19:11:12)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
    Description Free text field to be used if no code is available
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Organisation 0 … 1
    prsb03-dataelement-10974
    Id prsb03-dataelement-10974 (2019‑05‑22 16:31:40)
    Cardinality 0 … 1
    Description The organisation of the referrer.
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Coded value 0 … 1
    prsb03-dataelement-13399
    Id prsb03-dataelement-13399 (2020‑08‑10 19:14:38)
    Cardinality 0 … 1
    Description The coded value for organisation code
    Operationalization NHS data dictionary : - Organisation data service
    Value Domain
    Property
    min length max length
    3 5
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Free text 0 … 1
    prsb03-dataelement-13400
    Id prsb03-dataelement-13400 (2020‑08‑10 19:17:07)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
    Description Free text field to be used if no code is available
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Contact details 0 … 1
    prsb03-dataelement-10975
    Id prsb03-dataelement-10975 (2019‑05‑22 16:33:49)
    Cardinality 0 … 1
    Description The contact details of the referrer.
    Operationalization Free text
    Value Domain
    Property
    max length
    70
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Admission details 0 … 1
    prsb03-dataelement-181
    Id prsb03-dataelement-181 (2018‑10‑31)
    Cardinality 0 … 1
    Description Admission details
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Admission details record entry 0 … *
    prsb03-dataelement-10918
    Id prsb03-dataelement-10918 (2019‑04‑09 16:16:31)
    Cardinality 0 … *
    Description This is the admission details record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Date of admission 0 … 1
    prsb03-dataelement-10085
    Id prsb03-dataelement-10085 (2018‑10‑31)
    Cardinality 0 … 1
    Description Date and time the person was admitted to hospital.

    Properties

    FHIR Encounter.period
    Rationale Encounter.period
    Operationalization Date and time
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Admitted to 0 … 1
    prsb03-dataelement-10090
    Id prsb03-dataelement-10090 (2018‑10‑31)
    Cardinality 0 … 1
    notice There are open issues with this item:
    Description The hospital the person was admitted to.
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Coded value 0 … 1
    prsb03-dataelement-13380
    Id prsb03-dataelement-13380 (2020‑08‑10 18:02:32)
    Cardinality 0 … 1
    Description The coded value for admission to
    Operationalization NHS data dictionary : - Organisations code of provider
    Value Domain
    Property
    min length max length
    3 6
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Free text 0 … 1
    prsb03-dataelement-13381
    Id prsb03-dataelement-13381 (2020‑08‑10 18:03:47)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
    Description Free text field to be used if no code is available
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Responsible care professional 0 … 1
    prsb03-dataelement-10087
    Id prsb03-dataelement-10087 (2018‑10‑31)
    Cardinality 0 … 1
    Description The care professional who has overall responsibility for the person (may not actually see the person)
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Name 0 … 1
    prsb03-dataelement-10992
    Id prsb03-dataelement-10992 (2019‑05‑23 23:16:09)
    Cardinality 0 … 1
    Description The name of the responsible care professional.
    Rationale Encounter.Practitioner.PractitionerRole.Practitioner.name
    Operationalization Free text.
    Value Domain
    Property
    max length
    70
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Role 0 … 1
    prsb03-dataelement-10993
    Id prsb03-dataelement-10993 (2019‑05‑23 23:17:05)
    Cardinality 0 … 1
    Description The role of the responsible consultant.
    Rationale Encounter.Practitioner.PractitionerRole
    Operationalization FHIR value set: - sdsjobrole
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Reason for admission 0 … 1
    prsb03-dataelement-10081
    Id prsb03-dataelement-10081 (2018‑10‑31)
    Cardinality 0 … 1
    Description The health problems and issues experienced by the person that prompted the decision to admit to hospital e.g. chest pain, mental health crisis, blackout, fall, a specific procedure, intervention, investigation or treatment, non compliance with treatment.

    Properties

    FHIR Encounter.reason
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Coded value 0 … 1
    prsb03-dataelement-13382
    Id prsb03-dataelement-13382 (2020‑08‑10 18:08:34)
    Cardinality 0 … 1
    Description The coded value for reason for admission
    Rationale Encounter.reason
    Operationalization SNOMED CT: - ^1127581000000103 |Health issues simple reference set|
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Free text 0 … 1
    prsb03-dataelement-13384
    Id prsb03-dataelement-13384 (2020‑08‑10 18:18:25)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
    Description Free text field to be used if no code is available
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Admission method 0 … 1
    prsb03-dataelement-10082
    Id prsb03-dataelement-10082 (2018‑10‑31)
    Cardinality 0 … 1
    Description How the person was admitted to hospital e.g. elective, emergency, maternity, transfer etc.

    Properties

    FHIR Handled as text in the transfer of care
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Coded value 0 … 1
    prsb03-dataelement-13385
    Id prsb03-dataelement-13385 (2020‑08‑10 18:21:26)
    Cardinality 0 … 1
    Description The coded value for admission method
    Rationale Extension
    Operationalization NHS data dictionary : - Admission method
    Value Domain
    Property
    max length
    2
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Free text 0 … 1
    prsb03-dataelement-13387
    Id prsb03-dataelement-13387 (2020‑08‑10 18:22:33)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
    Description Free text field to be used if no code is available
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Source of admission 0 … 1
    prsb03-dataelement-10084
    Id prsb03-dataelement-10084 (2018‑10‑31)
    Cardinality 0 … 1
    Description Where the person was immediately prior to admission, e.g. usual place of residence, temporary place of residence, penal establishment.

    Properties

    FHIR Encounter.hospitalisation.admitsource
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Coded value 0 … 1
    prsb03-dataelement-13388
    Id prsb03-dataelement-13388 (2020‑08‑10 18:25:26)
    Cardinality 0 … 1
    Description The coded value of source of admission
    Rationale Encounter.hospitalisation.admitsource
    Operationalization NHS data dictionary :- Source of admission
    Value Domain
    Property
    max length fixed
    2 an2
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Free text 0 … 1
    prsb03-dataelement-13389
    Id prsb03-dataelement-13389 (2020‑08‑10 18:27:00)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
    Description Free text field to be used if no code is available
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Individual accompanying person 0 … 1
    prsb03-dataelement-10088
    Id prsb03-dataelement-10088 (2018‑10‑31)
    Cardinality 0 … 1
    Description Details of the accompanying individual and the extent to which they have provided the information about the person.
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Name 0 … 1
    prsb03-dataelement-10984
    Id prsb03-dataelement-10984 (2019‑05‑23 12:59:39)
    Cardinality 0 … 1
    Description Name of individual accompanying person.
    Operationalization Free text
    Value Domain
    Property
    max length
    70
    target Used by one transaction, 0 templates, inherited 0 times
     
    cancelled Role 0 … 1
    prsb03-dataelement-10985
    Id prsb03-dataelement-10985 (2019‑05‑23 13:00:07) 0.1
    Cardinality 0 … 1
    Description Role of the individual accompanying the person.
    Operationalization NHS data dictionary : - Care professional
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Relationship 0 … 1
    prsb03-dataelement-10986
    Id prsb03-dataelement-10986 (2019‑05‑23 13:02:20)
    Cardinality 0 … 1
    Description Relationship of individual accompanying the person.
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Coded value 0 … 1
    prsb03-dataelement-13517
    Id prsb03-dataelement-13517 (2020‑09‑04 12:30:42)
    Cardinality 0 … 1
    Description The coded value for relationship to person.
    Operationalization FHIR value set: - Relationship type
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Free text 0 … 1
    prsb03-dataelement-13518
    Id prsb03-dataelement-13518 (2020‑09‑04 12:31:40)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
    Description Free text field to be used if no code is available
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Comment 0 … 1
    prsb03-dataelement-12447
    Id prsb03-dataelement-12447 (2019‑06‑17 14:41:14)
    Cardinality 0 … 1
    Description Information about the extent to which the accompanying individual provided information about the person.
    Operationalization Free text.
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Specialty 0 … 1
    prsb03-dataelement-10089
    Id prsb03-dataelement-10089 (2018‑10‑31)
    Cardinality 0 … 1
    Description The specialty e.g. physiotherapy, oncology, mental health etc
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Coded value 0 … 1
    prsb03-dataelement-13390
    Id prsb03-dataelement-13390 (2020‑08‑10 18:29:53)
    Cardinality 0 … 1
    Description The coded value for specialty
    Operationalization NHS data dictionary :- Activity treatment function code
    Value Domain
    Property
    max length
    3
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Free text 0 … 1
    prsb03-dataelement-13391
    Id prsb03-dataelement-13391 (2020‑08‑10 18:31:31)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
    Description Free text field to be used if no code is available
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Discharge details 0 … 1
    prsb03-dataelement-191
    Id prsb03-dataelement-191 (2018‑10‑31)
    Cardinality 0 … 1
    Description Discharge details
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Discharge details record entry 0 … *
    prsb03-dataelement-10919
    Id prsb03-dataelement-10919 (2019‑04‑09 16:31:23)
    Cardinality 0 … *
    Description 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.
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Date of discharge 1 … 1 Mandatory
    prsb03-dataelement-10096
    Id prsb03-dataelement-10096 (2018‑10‑31)
    Cardinality 1 … 1 Mandatory
    Description The date and time of discharge

    Properties

    FHIR Encounter.period
    Rationale Encounter.period
    Operationalization Date and time
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Discharge location 0 … 1
    prsb03-dataelement-10095
    Id prsb03-dataelement-10095 (2018‑10‑31)
    Cardinality 0 … 1
    Description The hospital the person was discharged from.

    Properties

    FHIR Encounter.location.name
    Rationale Encounter.location.name
    Operationalization NHS data dictionary : - Organisation data service
    Value Domain
    Property
    min length max length
    3 5
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Discharging consultant 0 … 1
    prsb03-dataelement-10093
    Id prsb03-dataelement-10093 (2018‑10‑31)
    Cardinality 0 … 1
    Description The consultant responsible for the person at time of discharge.

    Properties

    FHIR Encounter.Prartitioner.PractitionerRole.identifier (local ID) Encounter.Prartitioner.PractitionerRole.code Encounter.Prartitioner.Practitioner.identifier Encounter.Prartitioner.PractitionerRole.Practitioner.name
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Name 0 … 1
    prsb03-dataelement-10994
    Id prsb03-dataelement-10994 (2019‑05‑23 23:22:01)
    Cardinality 0 … 1
    Description The name of the discharging consultant
    Rationale
    Encounter.Practitioner.PractitionerRole.Practitioner.name
    Operationalization Free text
    Value Domain
    Property
    max length
    70
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Role 0 … 1
    prsb03-dataelement-10995
    Id prsb03-dataelement-10995 (2019‑05‑23 23:22:48)
    Cardinality 0 … 1
    Description The role of the discharging consultant
    Rationale
    Encounter.Practitioner.PractitionerRole
    Operationalization FHIR value set : - sdsjobrole
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Discharge method 0 … 1
    prsb03-dataelement-10098
    Id prsb03-dataelement-10098 (2018‑10‑31)
    Cardinality 0 … 1
    Description The method of discharge from hospital e.g. person discharged on clinical advice or with clinical consent; person discharged him/herself or was discharged by a relative or advocate.

    Properties

    FHIR Handled as text in the transfer of care
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Coded value 0 … 1
    prsb03-dataelement-13393
    Id prsb03-dataelement-13393 (2020‑08‑10 18:53:34)
    Cardinality 0 … 1
    Description The coded value for discharge method
    Rationale Extension
    Operationalization NHS data dictionary : - Discharge method
    Value Domain
    Property
    max length
    1
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Free text 0 … 1
    prsb03-dataelement-13394
    Id prsb03-dataelement-13394 (2020‑08‑10 18:55:25)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
    Description Free text field to be used if no code is available
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Discharging specialty 0 … 1
    prsb03-dataelement-10094
    Id prsb03-dataelement-10094 (2018‑10‑31)
    Cardinality 0 … 1
    Description The specialty of the consultant responsible for the person at the time of discharge.
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Coded value 0 … 1
    prsb03-dataelement-13395
    Id prsb03-dataelement-13395 (2020‑08‑10 18:57:49)
    Cardinality 0 … 1
    Description The coded value for discharge speciality
    Rationale Encounter.participant.individual.Practitioner.Practitionerrole.speciality
    Operationalization NHS data dictionary : - Activity treatment function code
    Value Domain
    Property
    max length
    3
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Free text 0 … 1
    prsb03-dataelement-13396
    Id prsb03-dataelement-13396 (2020‑08‑10 18:59:31)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
    Description Free text field to be used if no code is available
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Discharging department 0 … 1
    prsb03-dataelement-10987
    Id prsb03-dataelement-10987 (2019‑05‑23 13:21:24)
    Cardinality 0 … 1
    Description The department from which the person is discharged.
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Discharge destination 0 … 1
    prsb03-dataelement-10099
    Id prsb03-dataelement-10099 (2018‑10‑31)
    Cardinality 0 … 1

    Properties

    FHIR Encounter.hospitalisation.destination.location. Address
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Discharge destination 0 … 1
    prsb03-dataelement-10100
    Id prsb03-dataelement-10100 (2018‑10‑31)
    Cardinality 0 … 1
    Description The destination of the person on discharge from hospital e.g. usual place of residence, NHS run care home.

    Properties

    FHIR A code from the NHS Data Dictionary Discharge Destination
    Rationale Encounter.hospitalisation.dischargedisposition
    Operationalization NHS data dictionary - Discharge destination.
    Value Domain
    Property
    max length
    2
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Discharge address 0 … 1
    prsb03-dataelement-10101
    Id prsb03-dataelement-10101 (2018‑10‑31)
    Cardinality 0 … 1
    Description Address to which the person is discharged if not the usual place of residence.

    Properties

    FHIR If the patient is discharged to their normal place of residence, no address is recorded on the discharge summary. Otherwise, an address other than the patient's usual place of residence may be provided by the patient or their representative.
    Rationale Encounter.hospitalisation.destination.location. Address
    Operationalization NHS data dictionary :- Address
    Value Domain
    Property
    min length max length
    35 175
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Problem list 1 … 1 Mandatory
    prsb03-dataelement-10927
    Id prsb03-dataelement-10927 (2019‑04‑30 17:00:00)
    Cardinality 1 … 1 Mandatory
    Description A summary of the problems that require investigation or treatment.
    target Used by one transaction, 0 templates, inherited once
     
    folder draft Problem list record entry 0 … *
    prsb03-dataelement-10928
    Id prsb03-dataelement-10928 (2019‑04‑30 17:01:01)
    Cardinality 0 … *
    Description 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.
    target Used by one transaction, 0 templates, inherited once
     
    draft Date 0 … 1
    prsb03-dataelement-10929
    Id prsb03-dataelement-10929 (2019‑04‑30 17:04:55)
    Cardinality 0 … 1
    Description The date the problem was identified.
    Relationship
    Operationalization Date and time
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited once
     
    folder draft Performing professional 0 … 1
    prsb03-dataelement-12133
    Id prsb03-dataelement-12133 (2019‑05‑31 16:03:47)
    Cardinality 0 … 1
    Description The professional who identified the problem.
    Relationship
    target Used by one transaction, 0 templates, inherited once
     
    draft Name 0 … 1
    prsb03-dataelement-12134
    Id prsb03-dataelement-12134 (2019‑05‑31 16:04:17)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
    Description The name of the professional.
    Rationale Practitioner.name
    Operationalization Free text.
    Value Domain
    Property
    max length
    70
    target Used by one transaction, 0 templates, inherited once
     
    draft Role 0 … 1
    prsb03-dataelement-12135
    Id prsb03-dataelement-12135 (2019‑05‑31 16:04:17)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11283 (2019‑05‑30 11:58:48)
    Description The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc
    Rationale Practitioner.PractitionerRole.code
    Operationalization FHIR value set :- SDSjobroletype
    Value Domain
    target Used by one transaction, 0 templates, inherited once
     
    draft Grade 0 … 1
    prsb03-dataelement-12136
    Id prsb03-dataelement-12136 (2019‑05‑31 16:04:17)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
    Description The grade of the professional.
    Rationale PractitionerRole.code
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited once
     
    draft Speciality 0 … 1
    prsb03-dataelement-12137
    Id prsb03-dataelement-12137 (2019‑05‑31 16:04:17)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11284 (2019‑05‑30 12:01:15)
    Description The specialty of the professional e.g. physiotherapy, oncology, mental health etc
    Rationale PractitionerRole.speciality
    Operationalization NHS data dictionary - Activity treatment function code
    Value Domain
    Property
    max length
    3
    target Used by one transaction, 0 templates, inherited once
     
    draft Professional identifier 0 … 1
    prsb03-dataelement-12138
    Id prsb03-dataelement-12138 (2019‑05‑31 16:04:17)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11285 (2019‑05‑30 12:02:46)
    Description Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.
    Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
    Operationalization NHS data dictionary : - Professional registration identifier
    Value Domain
    Property
    max length
    32
    target Used by one transaction, 0 templates, inherited once
     
    folder draft Organisation 0 … 1
    prsb03-dataelement-12139
    Id prsb03-dataelement-12139 (2019‑05‑31 16:04:17)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
    Description The name of the organisation the professional works for.
    target Used by one transaction, 0 templates, inherited once
     
    draft Contact details 0 … 1
    prsb03-dataelement-12140
    Id prsb03-dataelement-12140 (2019‑05‑31 16:04:17)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11287 (2019‑05‑30 12:18:13)
    Description Contact details of the professional
    Rationale Practitioner.telecom

    PractitionerRole.telecom

    Organisation.telcom
    Operationalization NHS data dictionary - UK phone number
    Value Domain
    Property
    max length
    35
    target Used by one transaction, 0 templates, inherited once
     
    folder draft Location 0 … 1
    prsb03-dataelement-10931
    Id prsb03-dataelement-10931 (2019‑04‑30 17:07:45)
    Cardinality 0 … 1
    Description The location the problem was identified.
    Relationship
    target Used by one transaction, 0 templates, inherited once
     
    draft Coded value 0 … 1
    prsb03-dataelement-13242
    Id prsb03-dataelement-13242 (2020‑07‑27 18:27:08)
    Cardinality 0 … 1
    Description The coded value for location.
    Operationalization NHS data dictionary : - Organisation data service code
    Value Domain
    Property
    min length max length
    3 5
    target Used by one transaction, 0 templates, inherited 4 times
     
    draft Free text 0 … 1
    prsb03-dataelement-13243
    Id prsb03-dataelement-13243 (2020‑07‑27 18:31:13)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
    Description Free text field to be used if no code is available
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 4 times
     
    folder draft Problem 1 … 1 Mandatory
    prsb03-dataelement-10932
    Id prsb03-dataelement-10932 (2019‑04‑30 17:08:40)
    Cardinality 1 … 1 Mandatory
    Context ‘Problems’ may also be ‘diagnoses’ or ‘issues’, depending on the context in which they are recorded. This would include disabilities, including learning disabilities, and conditions such as autism where they fall into the above categories i.e. are diagnosed, seen as a problem by the person or are considered a condition or similar. Behavioural factors which are not formal diagnoses but could be seen as a problem for the person would also appear under this section. 
    When a diagnosis has not yet been made, the most granular clinical concept with the highest level of certainty should be displayed. This may be a problem, symptom, sign, or test result, and may evolve over time, as a conventional diagnosis is reached. For example, ‘dyspepsia’ may be the diagnosis when a patient first presents with indigestion, upgraded to ‘gastric ulcer’ when this is found at endoscopy, and ‘gastric cancer’ when biopsies reveal this. 
    Unconfirmed or excluded diagnoses should not be coded but may be included in free text in the comments field. Thus, in the example above, gastric ulcer and gastric cancer may be in a list of differential diagnoses at presentation, but the symptom, dyspepsia, should be included in the diagnosis field. 
    The differential diagnoses should only be included in free text in the comments field, and not in a coded diagnosis field until confirmed with confidence.   
    Co-morbidities’ should be shown as separate diagnoses. For example, dementia may be recorded as a primary diagnosis by a psycho-geriatrician, but as a co- morbidity where a patient is admitted for a hip replacement. Local implementations will need to define what will be prioritised according to each use case. 
    In some situations, a diagnosis may need to be qualified by a number of attributes to give further detail e.g. grade; severity; distribution; behaviour; laterality etc. SNOMED CT codes are available for this purpose.

    Description 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
    Relationship
    target Used by one transaction, 0 templates, inherited 3 times
     
    draft Coded value 0 … 1
    prsb03-dataelement-13244
    Id prsb03-dataelement-13244 (2020‑07‑27 18:43:32)
    Cardinality 0 … 1
    Description The coded value for the problem list.
    Operationalization SNOMED CT : - ^1127581000000103 |Health issues simple reference set|
    Value Domain
    target Used by one transaction, 0 templates, inherited 2 times
     
    draft Free text 0 … 1
    prsb03-dataelement-13245
    Id prsb03-dataelement-13245 (2020‑07‑27 18:46:30)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
    Description Free text field to be used if no code is available
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 2 times
     
    draft Onset date 0 … 1
    prsb03-dataelement-10933
    Id prsb03-dataelement-10933 (2019‑04‑30 17:10:25)
    Cardinality 0 … 1
    Context ‘Onset date’ should be included where available even if this is estimated in source systems.
    Description A date or estimated date that the problem began
    Relationship
    Operationalization Date and time
    Value Domain
    Property
    Timestamp precision
    at least month and year
    target Used by one transaction, 0 templates, inherited once
     
    draft End Date 0 … 1
    prsb03-dataelement-10934
    Id prsb03-dataelement-10934 (2019‑04‑30 17:10:59)
    Cardinality 0 … 1
    Description The date or estimated date the problem was resolved.
    Relationship
    Operationalization Date and time.
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited once
     
    folder draft Problem on discharge 0 … 1
    prsb03-dataelement-14262
    Id prsb03-dataelement-14262 (2021‑03‑10 15:51:43)
    Cardinality 0 … 1
    Context
    The discharge summary should inform the GP of the main problem(s) / diagnoses that were important during the admission including any new diagnosis that came to light during the admission.
    When a diagnosis has not yet been made, the most granular clinical concept with the highest level of certainty should be recorded. This may be a problem, symptom, sign, or test result, and may evolve over time, as a conventional diagnosis is reached. For example, ‘dyspepsia’ may be the diagnosis when a patient first presents with indigestion, upgraded to ‘gastric ulcer’ when this is found at endoscopy, and ‘gastric cancer’ when biopsies reveal this.).
    Co-morbidities’ should be recorded as separate diagnoses. For example, dementia may be recorded as a primary diagnosis by a psycho-geriatrician, but as a co- morbidity where a patient is admitted for a hip replacement.
    Unconfirmed or excluded diagnoses or problems should not be recorded in structured coded fields, but may be listed in free text in the comments field. Thus, in the example above, gastric ulcer and gastric cancer may be in a list of differential diagnoses at presentation, but the symptom, dyspepsia, should be recorded in the problem list field. The differential diagnoses should only be recorded in free text in the comments field, and not in a coded field until confirmed with confidence.

    Description The main problem or diagnosis on discharge.

    Problems may include diagnoses, symptoms, disabilities and social or behavioural issues, and comprise the ‘Problem list’
    Relationship
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Coded value 0 … 1
    prsb03-dataelement-14263
    Id prsb03-dataelement-14263 (2021‑03‑10 15:53:09)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13244 (2020‑07‑27 18:43:32)
    Description The coded value for the problem list.
    Operationalization SNOMED CT : - ^1127581000000103 |Health issues simple reference set|
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Free text 0 … 1
    prsb03-dataelement-14264
    Id prsb03-dataelement-14264 (2021‑03‑10 15:53:09)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13245 (2020‑07‑27 18:46:30)
    Description Free text field to be used if no code is available
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Stage of disease 0 … 1
    prsb03-dataelement-10935
    Id prsb03-dataelement-10935 (2019‑04‑30 17:11:55)
    Cardinality 0 … 1
    Description The stage of the disease where relevant.
    Relationship
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited once
     
    folder draft Person completing record 0 … 1
    prsb03-dataelement-12141
    Id prsb03-dataelement-12141 (2019‑05‑31 16:04:31)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
    Description Details of the person completing the record.
    Relationship
    target Used by one transaction, 0 templates, inherited once
     
    draft Name 0 … 1
    prsb03-dataelement-12142
    Id prsb03-dataelement-12142 (2019‑05‑31 16:04:53)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11290 (2019‑05‑30 12:25:39)
    Description The name of the person completing the record.
    Relationship
    Rationale Composition.author.Practitioner.name
    Operationalization Free text.
    Value Domain
    Property
    max length
    70
    target Used by one transaction, 0 templates, inherited once
     
    draft Role 0 … 1
    prsb03-dataelement-12143
    Id prsb03-dataelement-12143 (2019‑05‑31 16:04:53)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
    Description The organisational role of the person completing record.

    Properties

    FHIR PractitionerRole.code of the practitioner completing the record
    Relationship
    Rationale Composition.author.Practitioner.PractitionerRole.code
    Operationalization FHIR value set :- SDSjobrole
    Value Domain
    target Used by one transaction, 0 templates, inherited once
     
    draft Grade 0 … 1
    prsb03-dataelement-12144
    Id prsb03-dataelement-12144 (2019‑05‑31 16:04:53)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11292 (2019‑05‑30 12:25:39)
    Description The grade of the person completing the record.
    Relationship
    Rationale PractitionerRole.code
    Operationalization Free text.
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited once
     
    draft Specialty 0 … 1
    prsb03-dataelement-12145
    Id prsb03-dataelement-12145 (2019‑05‑31 16:04:53)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11293 (2019‑05‑30 12:25:39)
    Description The main specialty of the person completing the record.

    Properties

    FHIR PractitionerRole.specialty
    Relationship
    Rationale PractitionerRole.speciality
    Operationalization NHS data dictionary :- Activity treatment function code
    Value Domain
    Property
    max length
    3
    target Used by one transaction, 0 templates, inherited once
     
    folder draft Organisation 0 … 1
    prsb03-dataelement-12146
    Id prsb03-dataelement-12146 (2019‑05‑31 16:04:53)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
    Description The organisation the person completing the record works for.
    Relationship
    Operationalization NHS data dictionary : - Organisation data service
    target Used by one transaction, 0 templates, inherited once
     
    draft Professional identifier 0 … 1
    prsb03-dataelement-12147
    Id prsb03-dataelement-12147 (2019‑05‑31 16:04:53)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11295 (2019‑05‑30 12:25:39)
    Description Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.

    Properties

    FHIR PractitionerRole.Practitioner.identifier (local) Practitioner.identifer (professional)
    Relationship
    Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
    Operationalization NHS data dictionary :- Professional registration identifier
    Value Domain
    Property
    max length
    32
    target Used by one transaction, 0 templates, inherited once
     
    draft Date completed 0 … 1
    prsb03-dataelement-12148
    Id prsb03-dataelement-12148 (2019‑05‑31 16:04:53)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11296 (2019‑05‑30 12:25:39)
    Description The date and time the record was completed.
    Relationship
    Rationale Composition.date
    Operationalization Date and time.
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited once
     
    draft Contact details 0 … 1
    prsb03-dataelement-12149
    Id prsb03-dataelement-12149 (2019‑05‑31 16:04:53)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
    Description Contact details of the person completing the record.

    Properties

    FHIR PractitionerRole.telecom
    Relationship
    Rationale Practitioner.telecom

    PractitionerRole.telecom

    Organisation.telcom
    Operationalization NHS data dictionary : - UK telephone number
    Value Domain
    Property
    max length
    35
    target Used by one transaction, 0 templates, inherited once
     
    draft Comment 0 … *
    prsb03-dataelement-10936
    Id prsb03-dataelement-10936 (2019‑04‑30 17:13:22)
    Cardinality 0 … *
    Description Supporting text may be given covering the problem.
    Relationship
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited once
     
    folder draft Procedures and therapies 0 … 1
    prsb03-dataelement-238
    Id prsb03-dataelement-238 (2018‑10‑31)
    Cardinality 0 … 1
    Description The details of any procedures performed. Includes both psychological and medical therapies and procedures (e.g. cognitive behaviour therapy, hip replacement)
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Procedure record entry 0 … *
    prsb03-dataelement-10652
    Id prsb03-dataelement-10652 (2018‑11‑13 12:02:22)
    Cardinality 0 … *
    Description 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.
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Date 0 … 1
    prsb03-dataelement-10138
    Id prsb03-dataelement-10138 (2018‑10‑31)
    Cardinality 0 … 1
    Description The date the procedure was performed.
    Operationalization Date and time.
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Location 0 … 1
    prsb03-dataelement-13246
    Id prsb03-dataelement-13246 (2020‑07‑27 19:13:27)
    Cardinality 0 … 1
    Description The location where the procedure was undertaken.
    Relationship
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Coded value 0 … 1
    prsb03-dataelement-13247
    Id prsb03-dataelement-13247 (2020‑07‑27 19:14:31)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13242 (2020‑07‑27 18:27:08)
    Description The coded value for location.
    Operationalization NHS data dictionary : - Organisation data service code
    Value Domain
    Property
    min length max length
    3 5
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Free text 0 … 1
    prsb03-dataelement-13248
    Id prsb03-dataelement-13248 (2020‑07‑27 19:14:31)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13243 (2020‑07‑27 18:31:13)
    Description Free text field to be used if no code is available
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Performing professional 0 … 1
    prsb03-dataelement-12150
    Id prsb03-dataelement-12150 (2019‑05‑31 16:08:40)
    Cardinality 0 … 1
    Description The professional who performed the procedure.
    Relationship
    target Used by one transaction, 0 templates, inherited once
     
    draft Name 0 … 1
    prsb03-dataelement-12151
    Id prsb03-dataelement-12151 (2019‑05‑31 16:09:20)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
    Description The name of the professional.
    Rationale Practitioner.name
    Operationalization Free text.
    Value Domain
    Property
    max length
    70
    target Used by one transaction, 0 templates, inherited once
     
    draft Role 0 … 1
    prsb03-dataelement-12152
    Id prsb03-dataelement-12152 (2019‑05‑31 16:09:20)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11283 (2019‑05‑30 11:58:48)
    Description The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc
    Rationale Practitioner.PractitionerRole.code
    Operationalization FHIR value set :- SDSjobroletype
    Value Domain
    target Used by one transaction, 0 templates, inherited once
     
    draft Grade 0 … 1
    prsb03-dataelement-12153
    Id prsb03-dataelement-12153 (2019‑05‑31 16:09:20)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
    Description The grade of the professional.
    Rationale PractitionerRole.code
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited once
     
    draft Speciality 0 … 1
    prsb03-dataelement-12154
    Id prsb03-dataelement-12154 (2019‑05‑31 16:09:20)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11284 (2019‑05‑30 12:01:15)
    Description The specialty of the professional e.g. physiotherapy, oncology, mental health etc
    Rationale PractitionerRole.speciality
    Operationalization NHS data dictionary - Activity treatment function code
    Value Domain
    Property
    max length
    3
    target Used by one transaction, 0 templates, inherited once
     
    draft Professional identifier 0 … 1
    prsb03-dataelement-12155
    Id prsb03-dataelement-12155 (2019‑05‑31 16:09:20)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11285 (2019‑05‑30 12:02:46)
    Description Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.
    Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
    Operationalization NHS data dictionary : - Professional registration identifier
    Value Domain
    Property
    max length
    32
    target Used by one transaction, 0 templates, inherited once
     
    folder draft Organisation 0 … 1
    prsb03-dataelement-12156
    Id prsb03-dataelement-12156 (2019‑05‑31 16:09:20)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
    Description The name of the organisation the professional works for.
    target Used by one transaction, 0 templates, inherited once
     
    draft Contact details 0 … 1
    prsb03-dataelement-12157
    Id prsb03-dataelement-12157 (2019‑05‑31 16:09:20)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11287 (2019‑05‑30 12:18:13)
    Description Contact details of the professional
    Rationale Practitioner.telecom

    PractitionerRole.telecom

    Organisation.telcom
    Operationalization NHS data dictionary - UK phone number
    Value Domain
    Property
    max length
    35
    target Used by one transaction, 0 templates, inherited once
     
    folder draft Procedure 1 … 1 Mandatory
    prsb03-dataelement-10141
    Id prsb03-dataelement-10141 (2018‑10‑31)
    Cardinality 1 … 1 Mandatory
    Context
    All procedures undertaken should be included in the e-discharge summary, including:
    •diagnostic as well as therapeutic procedures and therapies
    •medical as well as psychological procedures and therapies (e.g. cognitive behaviour therapy; follow-up interventions as a result of physical health checks)
    •procedures carried out on different days during the hospital stay.
    •complementary or alternative procedures and therapies 
    Outcomes or results of procedures should be recorded in the ‘comments’ field, as well as a comment to clarify such as statement that information is partial or incomplete.
    The discharge summary should include the operation which was actually carried out, not the planned procedure, as this may have been changed. The detail should be taken from the record of the actual procedure (e.g. operating note) rather than the planned procedure (e.g. consent to treatment).


    Description 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.

    Properties

    FHIR Procedure.code
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Coded value 0 … 1
    prsb03-dataelement-13249
    Id prsb03-dataelement-13249 (2020‑07‑27 19:35:09)
    Cardinality 0 … 1
    Context
    Clinical coders use discharge summaries for coding hospital episodes. All those deemed to be clinically important for future care should be listed. Thus venesection would not usually merit noting, unless undertaken as a therapeutic procedure for polycythaemia.
    Whilst hospitals use OPCS codes for procedures, these cannot be used by GP practices, so should not be included in discharge summaries.

    Description The procedure code.
    Operationalization SNOMED CT : - << 71388002 |Procedure| OR << 129125009 |Procedure with explicit context|
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Free text 0 … 1
    prsb03-dataelement-13250
    Id prsb03-dataelement-13250 (2020‑07‑27 19:40:38)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
    Description Free text field to be used if no code is available
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Anatomical site 0 … 1
    prsb03-dataelement-10142
    Id prsb03-dataelement-10142 (2018‑10‑31)
    Cardinality 0 … 1
    Context The procedure, anatomical site and laterality should be SNOMED CT coded wherever possible, with free text as an option where this is not possible. 
    Description The body site of the procedure

    Properties

    FHIR Procedure.bodySite
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Coded value 0 … 1
    prsb03-dataelement-13251
    Id prsb03-dataelement-13251 (2020‑07‑27 19:46:07)
    Cardinality 0 … 1
    Description The coded value of the anatomical site.
    Operationalization SNOMED CT :- < 123037004 |Body structure (body structure)|
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Free text 0 … 1
    prsb03-dataelement-13252
    Id prsb03-dataelement-13252 (2020‑07‑27 19:48:24)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
    Description Free text field to be used if no code is available
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Laterality 0 … 1
    prsb03-dataelement-10143
    Id prsb03-dataelement-10143 (2018‑10‑31)
    Cardinality 0 … 1
    Description Laterality of the procedure

    Properties

    FHIR ??Procedure.Code as an EXPRESSION Procedure.bodySite
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Coded value 0 … 1
    prsb03-dataelement-13253
    Id prsb03-dataelement-13253 (2020‑07‑27 19:50:39)
    Cardinality 0 … 1
    Description The coded value for laterality.
    Operationalization SNOMED CT:- < 182353008 |Side (qualifier value)|
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Free text 0 … 1
    prsb03-dataelement-13254
    Id prsb03-dataelement-13254 (2020‑07‑27 19:52:35)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
    Description Free text field to be used if no code is available
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Complications related to procedure 0 … 1
    prsb03-dataelement-10144
    Id prsb03-dataelement-10144 (2018‑10‑31)
    Cardinality 0 … 1
    Description 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.

    Properties

    FHIR Procedure.complication Procedure.complicationDetail
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Coded value 0 … 1
    prsb03-dataelement-13255
    Id prsb03-dataelement-13255 (2020‑07‑27 19:56:23)
    Cardinality 0 … 1
    Description The coded value for complications relating to procedure.
    Operationalization SNOMED CT : - < 404684003 |Clinical finding (finding)|

    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Free text 0 … 1
    prsb03-dataelement-13256
    Id prsb03-dataelement-13256 (2020‑07‑27 19:58:17)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
    Description Free text field to be used if no code is available
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Specific anesthesia issues 0 … 1
    prsb03-dataelement-10145
    Id prsb03-dataelement-10145 (2018‑10‑31)
    Cardinality 0 … 1
    Context
    There are specific elements for complications relating to the procedure and anaesthetic issues.
    The anaesthesia issues included could be, for example, “short neck, difficult to intubate” and the actual intubation grade or adverse reactions.

    Description Details of any adverse reaction to any anesthetic agents including local anesthesia. Problematic intubation, transfusion reaction, etc.

    Properties

    FHIR Procedure. Procedure.AnestheticIssues
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Coded value 0 … 1
    prsb03-dataelement-13257
    Id prsb03-dataelement-13257 (2020‑07‑27 20:00:25)
    Cardinality 0 … 1
    Description The coded value for specific anesthesia issues.
    Operationalization SNOMED CT
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Free text 0 … 1
    prsb03-dataelement-13258
    Id prsb03-dataelement-13258 (2020‑07‑27 20:01:36)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
    Description Free text field to be used if no code is available
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Person completing record 0 … 1
    prsb03-dataelement-12158
    Id prsb03-dataelement-12158 (2019‑05‑31 16:09:35)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
    Description Details of the person completing the record.
    Relationship
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Name 0 … 1
    prsb03-dataelement-12159
    Id prsb03-dataelement-12159 (2019‑05‑31 16:10:02)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11290 (2019‑05‑30 12:25:39)
    Description The name of the person completing the record.
    Relationship
    Rationale Composition.author.Practitioner.name
    Operationalization Free text.
    Value Domain
    Property
    max length
    70
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Role 0 … 1
    prsb03-dataelement-12160
    Id prsb03-dataelement-12160 (2019‑05‑31 16:10:02)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
    Description The organisational role of the person completing record.

    Properties

    FHIR PractitionerRole.code of the practitioner completing the record
    Relationship
    Rationale Composition.author.Practitioner.PractitionerRole.code
    Operationalization FHIR value set :- SDSjobrole
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Grade 0 … 1
    prsb03-dataelement-12161
    Id prsb03-dataelement-12161 (2019‑05‑31 16:10:02)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11292 (2019‑05‑30 12:25:39)
    Description The grade of the person completing the record.
    Relationship
    Rationale PractitionerRole.code
    Operationalization Free text.
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Specialty 0 … 1
    prsb03-dataelement-12162
    Id prsb03-dataelement-12162 (2019‑05‑31 16:10:02)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11293 (2019‑05‑30 12:25:39)
    Description The main specialty of the person completing the record.

    Properties

    FHIR PractitionerRole.specialty
    Relationship
    Rationale PractitionerRole.speciality
    Operationalization NHS data dictionary :- Activity treatment function code
    Value Domain
    Property
    max length
    3
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Organisation 0 … 1
    prsb03-dataelement-12163
    Id prsb03-dataelement-12163 (2019‑05‑31 16:10:02)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
    Description The organisation the person completing the record works for.
    Relationship
    Operationalization NHS data dictionary : - Organisation data service
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Professional identifier 0 … 1
    prsb03-dataelement-12164
    Id prsb03-dataelement-12164 (2019‑05‑31 16:10:02)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11295 (2019‑05‑30 12:25:39)
    Description Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.

    Properties

    FHIR PractitionerRole.Practitioner.identifier (local) Practitioner.identifer (professional)
    Relationship
    Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
    Operationalization NHS data dictionary :- Professional registration identifier
    Value Domain
    Property
    max length
    32
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Date completed 0 … 1
    prsb03-dataelement-12165
    Id prsb03-dataelement-12165 (2019‑05‑31 16:10:02)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11296 (2019‑05‑30 12:25:39)
    Description The date and time the record was completed.
    Relationship
    Rationale Composition.date
    Operationalization Date and time.
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Contact details 0 … 1
    prsb03-dataelement-12166
    Id prsb03-dataelement-12166 (2019‑05‑31 16:10:02)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
    Description Contact details of the person completing the record.

    Properties

    FHIR PractitionerRole.telecom
    Relationship
    Rationale Practitioner.telecom

    PractitionerRole.telecom

    Organisation.telcom
    Operationalization NHS data dictionary : - UK telephone number
    Value Domain
    Property
    max length
    35
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Comment 0 … 1
    prsb03-dataelement-10146
    Id prsb03-dataelement-10146 (2018‑10‑31)
    Cardinality 0 … 1
    Description Any further textual comment to clarify such as statement that information is partial or incomplete. Also indicate the outcome of the procedure.

    Properties

    FHIR Procedure.note
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Clinical Summary 1 … 1 Mandatory
    prsb03-dataelement-247
    Id prsb03-dataelement-247 (2018‑10‑31)
    Cardinality 1 … 1 Mandatory
    Description Clinical Summary
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Clinical summary 1 … 1 Mandatory
    prsb03-dataelement-10147
    Id prsb03-dataelement-10147 (2018‑10‑31)
    Cardinality 1 … 1 Mandatory
    Description 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’.
    Operationalization Free text
    Value Domain
    target Used by one transaction, 0 templates, inherited once
     
    folder draft Social context 0 … 1
    prsb03-dataelement-136
    Id prsb03-dataelement-136 (2018‑10‑31)
    Cardinality 0 … 1
    Description The social setting in which the person lives, such as their household, occupational history, and lifestyle factors.
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Household composition 0 … 1
    prsb03-dataelement-10036
    Id prsb03-dataelement-10036 (2018‑10‑31)
    Cardinality 0 … 1
    Description Details of the person's household composition.
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Date 0 … 1
    prsb03-dataelement-11770
    Id prsb03-dataelement-11770 (2019‑05‑31 14:13:42)
    Cardinality 0 … 1
    Description The date when the household composition was taken.
    Relationship
    Operationalization Date and time.
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Location 0 … 1
    prsb03-dataelement-13271
    Id prsb03-dataelement-13271 (2020‑07‑28 14:07:57)
    Cardinality 0 … 1
    Description The location where the household composition was taken.
    Relationship
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Coded value 0 … 1
    prsb03-dataelement-13272
    Id prsb03-dataelement-13272 (2020‑07‑28 14:09:11)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13242 (2020‑07‑27 18:27:08)
    Description The coded value for location.
    Operationalization NHS data dictionary : - Organisation data service code
    Value Domain
    Property
    min length max length
    3 5
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Free text 0 … 1
    prsb03-dataelement-13273
    Id prsb03-dataelement-13273 (2020‑07‑28 14:09:11)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13243 (2020‑07‑27 18:31:13)
    Description Free text field to be used if no code is available
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Household composition 0 … 1
    prsb03-dataelement-13261
    Id prsb03-dataelement-13261 (2020‑07‑28 12:00:25)
    Cardinality 0 … 1
    Description Description of the household composition e.g. lives alone, lives with family, lives with partner, shared accommodation etc.
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Coded value 0 … 1
    prsb03-dataelement-13262
    Id prsb03-dataelement-13262 (2020‑07‑28 12:15:50)
    Cardinality 0 … 1
    Description The coded value of household composition
    Operationalization SNOMED CT: - 1027891000000106 | Household composition findings simple reference set (foundation metadata concept) |
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Free text 0 … 1
    prsb03-dataelement-13263
    Id prsb03-dataelement-13263 (2020‑07‑28 12:20:28)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
    Description Free text field to be used if no code is available
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Performing professional 0 … 1
    prsb03-dataelement-11648
    Id prsb03-dataelement-11648 (2019‑05‑30 18:03:53)
    Cardinality 0 … 1
    Description The professional who took the household composition.
    Relationship
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Name 0 … 1
    prsb03-dataelement-11649
    Id prsb03-dataelement-11649 (2019‑05‑30 18:07:33)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
    Description The name of the professional.
    Rationale Practitioner.name
    Operationalization Free text.
    Value Domain
    Property
    max length
    70
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Role 0 … 1
    prsb03-dataelement-11650
    Id prsb03-dataelement-11650 (2019‑05‑30 18:07:33)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11283 (2019‑05‑30 11:58:48)
    Description The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc
    Rationale Practitioner.PractitionerRole.code
    Operationalization FHIR value set :- SDSjobroletype
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Grade 0 … 1
    prsb03-dataelement-11651
    Id prsb03-dataelement-11651 (2019‑05‑30 18:07:33)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
    Description The grade of the professional.
    Rationale PractitionerRole.code
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Speciality 0 … 1
    prsb03-dataelement-11652
    Id prsb03-dataelement-11652 (2019‑05‑30 18:07:33)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11284 (2019‑05‑30 12:01:15)
    Description The specialty of the professional e.g. physiotherapy, oncology, mental health etc
    Rationale PractitionerRole.speciality
    Operationalization NHS data dictionary - Activity treatment function code
    Value Domain
    Property
    max length
    3
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Professional identifier 0 … 1
    prsb03-dataelement-11653
    Id prsb03-dataelement-11653 (2019‑05‑30 18:07:33)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11285 (2019‑05‑30 12:02:46)
    Description Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.
    Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
    Operationalization NHS data dictionary : - Professional registration identifier
    Value Domain
    Property
    max length
    32
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Organisation 0 … 1
    prsb03-dataelement-11654
    Id prsb03-dataelement-11654 (2019‑05‑30 18:07:33)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
    Description The name of the organisation the professional works for.
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Contact details 0 … 1
    prsb03-dataelement-11655
    Id prsb03-dataelement-11655 (2019‑05‑30 18:07:33)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11287 (2019‑05‑30 12:18:13)
    Description Contact details of the professional
    Rationale Practitioner.telecom

    PractitionerRole.telecom

    Organisation.telcom
    Operationalization NHS data dictionary - UK phone number
    Value Domain
    Property
    max length
    35
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Person completing record 0 … 1
    prsb03-dataelement-11521
    Id prsb03-dataelement-11521 (2019‑05‑30 14:50:23)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
    Description Details of the person completing the record.
    Relationship
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Name 0 … 1
    prsb03-dataelement-11522
    Id prsb03-dataelement-11522 (2019‑05‑30 14:50:56)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11290 (2019‑05‑30 12:25:39)
    Description The name of the person completing the record.
    Relationship
    Rationale Composition.author.Practitioner.name
    Operationalization Free text.
    Value Domain
    Property
    max length
    70
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Role 0 … 1
    prsb03-dataelement-11523
    Id prsb03-dataelement-11523 (2019‑05‑30 14:50:56)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
    Description The organisational role of the person completing record.

    Properties

    FHIR PractitionerRole.code of the practitioner completing the record
    Relationship
    Rationale Composition.author.Practitioner.PractitionerRole.code
    Operationalization FHIR value set :- SDSjobrole
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Grade 0 … 1
    prsb03-dataelement-11524
    Id prsb03-dataelement-11524 (2019‑05‑30 14:50:56)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11292 (2019‑05‑30 12:25:39)
    Description The grade of the person completing the record.
    Relationship
    Rationale PractitionerRole.code
    Operationalization Free text.
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Specialty 0 … 1
    prsb03-dataelement-11525
    Id prsb03-dataelement-11525 (2019‑05‑30 14:50:56)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11293 (2019‑05‑30 12:25:39)
    Description The main specialty of the person completing the record.

    Properties

    FHIR PractitionerRole.specialty
    Relationship
    Rationale PractitionerRole.speciality
    Operationalization NHS data dictionary :- Activity treatment function code
    Value Domain
    Property
    max length
    3
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Organisation 0 … 1
    prsb03-dataelement-11526
    Id prsb03-dataelement-11526 (2019‑05‑30 14:50:56)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
    Description The organisation the person completing the record works for.
    Relationship
    Operationalization NHS data dictionary : - Organisation data service
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Professional identifier 0 … 1
    prsb03-dataelement-11527
    Id prsb03-dataelement-11527 (2019‑05‑30 14:50:56)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11295 (2019‑05‑30 12:25:39)
    Description Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.

    Properties

    FHIR PractitionerRole.Practitioner.identifier (local) Practitioner.identifer (professional)
    Relationship
    Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
    Operationalization NHS data dictionary :- Professional registration identifier
    Value Domain
    Property
    max length
    32
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Date completed 0 … 1
    prsb03-dataelement-11528
    Id prsb03-dataelement-11528 (2019‑05‑30 14:50:56)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11296 (2019‑05‑30 12:25:39)
    Description The date and time the record was completed.
    Relationship
    Rationale Composition.date
    Operationalization Date and time.
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Contact details 0 … 1
    prsb03-dataelement-11529
    Id prsb03-dataelement-11529 (2019‑05‑30 14:50:56)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
    Description Contact details of the person completing the record.

    Properties

    FHIR PractitionerRole.telecom
    Relationship
    Rationale Practitioner.telecom

    PractitionerRole.telecom

    Organisation.telcom
    Operationalization NHS data dictionary : - UK telephone number
    Value Domain
    Property
    max length
    35
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Occupational history 0 … 1
    prsb03-dataelement-10037
    Id prsb03-dataelement-10037 (2018‑10‑31)
    Cardinality 0 … 1
    Description The current and/or previous occupation(s) of the person.

    Properties

    FHIR Observation.category Observation.code Observation.valueCodeabelConcept Observation.subject
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Date 0 … 1
    prsb03-dataelement-11772
    Id prsb03-dataelement-11772 (2019‑05‑31 14:15:12)
    Cardinality 0 … 1
    Description The date when the occupational history was taken.
    Relationship
    Operationalization Date and time.
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Location 0 … 1
    prsb03-dataelement-11773
    Id prsb03-dataelement-11773 (2019‑05‑31 14:15:38)
    Cardinality 0 … 1
    Description The location where the occupational history was taken.
    Relationship
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Coded value 0 … 1
    prsb03-dataelement-13274
    Id prsb03-dataelement-13274 (2020‑07‑30 14:41:27)
    Cardinality 0 … 1
    Description The coded value for the location.
    Operationalization NHS Data dictionary : - Organisation data service code
    Value Domain
    Property
    min length max length
    3 5
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Free text 0 … 1
    prsb03-dataelement-13275
    Id prsb03-dataelement-13275 (2020‑07‑30 14:44:58)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
    Description Free text field to be used if no code is available
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Occupational history 0 … 1
    prsb03-dataelement-13264
    Id prsb03-dataelement-13264 (2020‑07‑28 12:26:39)
    Cardinality 0 … 1
    Description The current and/or previous occupation(s) of the person.
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Coded value 0 … 1
    prsb03-dataelement-13265
    Id prsb03-dataelement-13265 (2020‑07‑28 12:27:26)
    Cardinality 0 … 1
    Description The coded value for occupational history
    Operationalization SNOMED CT : - ^ 999001571000000109 | Occupation simple reference set (foundation metadata concept)
    Value Domain
    target Used by one transaction, 0 templates, inherited once
     
    draft Free text 0 … 1
    prsb03-dataelement-13266
    Id prsb03-dataelement-13266 (2020‑07‑28 12:29:14)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
    Description Free text field to be used if no code is available
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Performing professional 0 … 1
    prsb03-dataelement-11656
    Id prsb03-dataelement-11656 (2019‑05‑30 18:08:03)
    Cardinality 0 … 1
    Description The professional who took the occupational history.
    Relationship
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Name 0 … 1
    prsb03-dataelement-11657
    Id prsb03-dataelement-11657 (2019‑05‑30 18:08:20)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
    Description The name of the professional.
    Rationale Practitioner.name
    Operationalization Free text.
    Value Domain
    Property
    max length
    70
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Role 0 … 1
    prsb03-dataelement-11658
    Id prsb03-dataelement-11658 (2019‑05‑30 18:08:20)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11283 (2019‑05‑30 11:58:48)
    Description The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc
    Rationale Practitioner.PractitionerRole.code
    Operationalization FHIR value set :- SDSjobroletype
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Grade 0 … 1
    prsb03-dataelement-11659
    Id prsb03-dataelement-11659 (2019‑05‑30 18:08:20)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
    Description The grade of the professional.
    Rationale PractitionerRole.code
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Speciality 0 … 1
    prsb03-dataelement-11660
    Id prsb03-dataelement-11660 (2019‑05‑30 18:08:20)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11284 (2019‑05‑30 12:01:15)
    Description The specialty of the professional e.g. physiotherapy, oncology, mental health etc
    Rationale PractitionerRole.speciality
    Operationalization NHS data dictionary - Activity treatment function code
    Value Domain
    Property
    max length
    3
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Professional identifier 0 … 1
    prsb03-dataelement-11661
    Id prsb03-dataelement-11661 (2019‑05‑30 18:08:20)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11285 (2019‑05‑30 12:02:46)
    Description Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.
    Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
    Operationalization NHS data dictionary : - Professional registration identifier
    Value Domain
    Property
    max length
    32
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Organisation 0 … 1
    prsb03-dataelement-11662
    Id prsb03-dataelement-11662 (2019‑05‑30 18:08:20)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
    Description The name of the organisation the professional works for.
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Contact details 0 … 1
    prsb03-dataelement-11663
    Id prsb03-dataelement-11663 (2019‑05‑30 18:08:20)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11287 (2019‑05‑30 12:18:13)
    Description Contact details of the professional
    Rationale Practitioner.telecom

    PractitionerRole.telecom

    Organisation.telcom
    Operationalization NHS data dictionary - UK phone number
    Value Domain
    Property
    max length
    35
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Person completing record 0 … 1
    prsb03-dataelement-11530
    Id prsb03-dataelement-11530 (2019‑05‑30 14:51:51)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
    Description Details of the person completing the record.
    Relationship
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Name 0 … 1
    prsb03-dataelement-11531
    Id prsb03-dataelement-11531 (2019‑05‑30 14:52:22)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11290 (2019‑05‑30 12:25:39)
    Description The name of the person completing the record.
    Relationship
    Rationale Composition.author.Practitioner.name
    Operationalization Free text.
    Value Domain
    Property
    max length
    70
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Role 0 … 1
    prsb03-dataelement-11532
    Id prsb03-dataelement-11532 (2019‑05‑30 14:52:22)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
    Description The organisational role of the person completing record.

    Properties

    FHIR PractitionerRole.code of the practitioner completing the record
    Relationship
    Rationale Composition.author.Practitioner.PractitionerRole.code
    Operationalization FHIR value set :- SDSjobrole
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Grade 0 … 1
    prsb03-dataelement-11533
    Id prsb03-dataelement-11533 (2019‑05‑30 14:52:22)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11292 (2019‑05‑30 12:25:39)
    Description The grade of the person completing the record.
    Relationship
    Rationale PractitionerRole.code
    Operationalization Free text.
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Specialty 0 … 1
    prsb03-dataelement-11534
    Id prsb03-dataelement-11534 (2019‑05‑30 14:52:22)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11293 (2019‑05‑30 12:25:39)
    Description The main specialty of the person completing the record.

    Properties

    FHIR PractitionerRole.specialty
    Relationship
    Rationale PractitionerRole.speciality
    Operationalization NHS data dictionary :- Activity treatment function code
    Value Domain
    Property
    max length
    3
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Organisation 0 … 1
    prsb03-dataelement-11535
    Id prsb03-dataelement-11535 (2019‑05‑30 14:52:22)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
    Description The organisation the person completing the record works for.
    Relationship
    Operationalization NHS data dictionary : - Organisation data service
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Professional identifier 0 … 1
    prsb03-dataelement-11536
    Id prsb03-dataelement-11536 (2019‑05‑30 14:52:22)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11295 (2019‑05‑30 12:25:39)
    Description Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.

    Properties

    FHIR PractitionerRole.Practitioner.identifier (local) Practitioner.identifer (professional)
    Relationship
    Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
    Operationalization NHS data dictionary :- Professional registration identifier
    Value Domain
    Property
    max length
    32
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Date completed 0 … 1
    prsb03-dataelement-11537
    Id prsb03-dataelement-11537 (2019‑05‑30 14:52:22)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11296 (2019‑05‑30 12:25:39)
    Description The date and time the record was completed.
    Relationship
    Rationale Composition.date
    Operationalization Date and time.
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Contact details 0 … 1
    prsb03-dataelement-11538
    Id prsb03-dataelement-11538 (2019‑05‑30 14:52:22)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
    Description Contact details of the person completing the record.

    Properties

    FHIR PractitionerRole.telecom
    Relationship
    Rationale Practitioner.telecom

    PractitionerRole.telecom

    Organisation.telcom
    Operationalization NHS data dictionary : - UK telephone number
    Value Domain
    Property
    max length
    35
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Educational history 0 … 1
    prsb03-dataelement-10038
    Id prsb03-dataelement-10038 (2018‑10‑31)
    Cardinality 0 … 1
    Description Details of the person's educational history.
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Date 0 … 1
    prsb03-dataelement-11774
    Id prsb03-dataelement-11774 (2019‑05‑31 14:16:22)
    Cardinality 0 … 1
    Description The date when the educational history was taken.
    Relationship
    Operationalization Date and time.
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Location 0 … 1
    prsb03-dataelement-11775
    Id prsb03-dataelement-11775 (2019‑05‑31 14:16:57)
    Cardinality 0 … 1
    Description The location where the education history was taken.
    Relationship
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Coded value 0 … 1
    prsb03-dataelement-13276
    Id prsb03-dataelement-13276 (2020‑07‑30 14:53:55)
    Cardinality 0 … 1
    Description The coded value for location.
    Operationalization NHS Data dictionary : - Organisation data service code
    Value Domain
    Property
    min length max length
    3 5
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Free text 0 … 1
    prsb03-dataelement-13277
    Id prsb03-dataelement-13277 (2020‑07‑30 14:55:09)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
    Description Free text field to be used if no code is available
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Educational history 0 … 1
    prsb03-dataelement-13840
    Id prsb03-dataelement-13840 (2020‑12‑29 11:11:55)
    Cardinality 0 … 1
    Description The current and/or previous relevant educational history of the person.
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Performing professional 0 … 1
    prsb03-dataelement-11776
    Id prsb03-dataelement-11776 (2019‑05‑31 14:17:28)
    Cardinality 0 … 1
    Description The professional who took the educational history.
    Relationship
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Name 0 … 1
    prsb03-dataelement-11777
    Id prsb03-dataelement-11777 (2019‑05‑31 14:17:50)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
    Description The name of the professional.
    Rationale Practitioner.name
    Operationalization Free text.
    Value Domain
    Property
    max length
    70
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Role 0 … 1
    prsb03-dataelement-11778
    Id prsb03-dataelement-11778 (2019‑05‑31 14:17:50)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11283 (2019‑05‑30 11:58:48)
    Description The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc
    Rationale Practitioner.PractitionerRole.code
    Operationalization FHIR value set :- SDSjobroletype
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Grade 0 … 1
    prsb03-dataelement-11779
    Id prsb03-dataelement-11779 (2019‑05‑31 14:17:50)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
    Description The grade of the professional.
    Rationale PractitionerRole.code
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Speciality 0 … 1
    prsb03-dataelement-11780
    Id prsb03-dataelement-11780 (2019‑05‑31 14:17:50)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11284 (2019‑05‑30 12:01:15)
    Description The specialty of the professional e.g. physiotherapy, oncology, mental health etc
    Rationale PractitionerRole.speciality
    Operationalization NHS data dictionary - Activity treatment function code
    Value Domain
    Property
    max length
    3
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Professional identifier 0 … 1
    prsb03-dataelement-11781
    Id prsb03-dataelement-11781 (2019‑05‑31 14:17:50)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11285 (2019‑05‑30 12:02:46)
    Description Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.
    Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
    Operationalization NHS data dictionary : - Professional registration identifier
    Value Domain
    Property
    max length
    32
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Organisation 0 … 1
    prsb03-dataelement-11782
    Id prsb03-dataelement-11782 (2019‑05‑31 14:17:50)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
    Description The name of the organisation the professional works for.
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Contact details 0 … 1
    prsb03-dataelement-11783
    Id prsb03-dataelement-11783 (2019‑05‑31 14:17:50)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11287 (2019‑05‑30 12:18:13)
    Description Contact details of the professional
    Rationale Practitioner.telecom

    PractitionerRole.telecom

    Organisation.telcom
    Operationalization NHS data dictionary - UK phone number
    Value Domain
    Property
    max length
    35
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Person completing record 0 … 1
    prsb03-dataelement-11539
    Id prsb03-dataelement-11539 (2019‑05‑30 14:52:55)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
    Description Details of the person completing the record.
    Relationship
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Name 0 … 1
    prsb03-dataelement-11540
    Id prsb03-dataelement-11540 (2019‑05‑30 14:53:14)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11290 (2019‑05‑30 12:25:39)
    Description The name of the person completing the record.
    Relationship
    Rationale Composition.author.Practitioner.name
    Operationalization Free text.
    Value Domain
    Property
    max length
    70
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Role 0 … 1
    prsb03-dataelement-11541
    Id prsb03-dataelement-11541 (2019‑05‑30 14:53:14)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
    Description The organisational role of the person completing record.

    Properties

    FHIR PractitionerRole.code of the practitioner completing the record
    Relationship
    Rationale Composition.author.Practitioner.PractitionerRole.code
    Operationalization FHIR value set :- SDSjobrole
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Grade 0 … 1
    prsb03-dataelement-11542
    Id prsb03-dataelement-11542 (2019‑05‑30 14:53:14)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11292 (2019‑05‑30 12:25:39)
    Description The grade of the person completing the record.
    Relationship
    Rationale PractitionerRole.code
    Operationalization Free text.
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Specialty 0 … 1
    prsb03-dataelement-11543
    Id prsb03-dataelement-11543 (2019‑05‑30 14:53:14)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11293 (2019‑05‑30 12:25:39)
    Description The main specialty of the person completing the record.

    Properties

    FHIR PractitionerRole.specialty
    Relationship
    Rationale PractitionerRole.speciality
    Operationalization NHS data dictionary :- Activity treatment function code
    Value Domain
    Property
    max length
    3
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Organisation 0 … 1
    prsb03-dataelement-11544
    Id prsb03-dataelement-11544 (2019‑05‑30 14:53:14)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
    Description The organisation the person completing the record works for.
    Relationship
    Operationalization NHS data dictionary : - Organisation data service
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Professional identifier 0 … 1
    prsb03-dataelement-11545
    Id prsb03-dataelement-11545 (2019‑05‑30 14:53:14)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11295 (2019‑05‑30 12:25:39)
    Description Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.

    Properties

    FHIR PractitionerRole.Practitioner.identifier (local) Practitioner.identifer (professional)
    Relationship
    Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
    Operationalization NHS data dictionary :- Professional registration identifier
    Value Domain
    Property
    max length
    32
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Date completed 0 … 1
    prsb03-dataelement-11546
    Id prsb03-dataelement-11546 (2019‑05‑30 14:53:14)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11296 (2019‑05‑30 12:25:39)
    Description The date and time the record was completed.
    Relationship
    Rationale Composition.date
    Operationalization Date and time.
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Contact details 0 … 1
    prsb03-dataelement-11547
    Id prsb03-dataelement-11547 (2019‑05‑30 14:53:14)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
    Description Contact details of the person completing the record.

    Properties

    FHIR PractitionerRole.telecom
    Relationship
    Rationale Practitioner.telecom

    PractitionerRole.telecom

    Organisation.telcom
    Operationalization NHS data dictionary : - UK telephone number
    Value Domain
    Property
    max length
    35
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Investigation results 0 … 1
    prsb03-dataelement-257
    Id prsb03-dataelement-257 (2018‑10‑31)
    Cardinality 0 … 1
    Description Investigation results
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Investigation results record entry 0 … *
    prsb03-dataelement-10654
    Id prsb03-dataelement-10654 (2018‑11‑13 12:10:48)
    Cardinality 0 … *
    Description This is a investigation result record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Date 0 … 1
    prsb03-dataelement-10157
    Id prsb03-dataelement-10157 (2018‑10‑31)
    Cardinality 0 … 1
    Description The date and time when the investigation was performed
    Operationalization Date and time
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Performing professional 0 … 1
    prsb03-dataelement-12099
    Id prsb03-dataelement-12099 (2019‑05‑31 15:55:11)
    Cardinality 0 … 1
    Description The professional who performed the investigation.
    Relationship
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Name 0 … 1
    prsb03-dataelement-12100
    Id prsb03-dataelement-12100 (2019‑05‑31 15:55:33)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
    Description The name of the professional.
    Rationale Practitioner.name
    Operationalization Free text.
    Value Domain
    Property
    max length
    70
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Role 0 … 1
    prsb03-dataelement-12101
    Id prsb03-dataelement-12101 (2019‑05‑31 15:55:33)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11283 (2019‑05‑30 11:58:48)
    Description The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc
    Rationale Practitioner.PractitionerRole.code
    Operationalization FHIR value set :- SDSjobroletype
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Grade 0 … 1
    prsb03-dataelement-12102
    Id prsb03-dataelement-12102 (2019‑05‑31 15:55:33)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
    Description The grade of the professional.
    Rationale PractitionerRole.code
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Speciality 0 … 1
    prsb03-dataelement-12103
    Id prsb03-dataelement-12103 (2019‑05‑31 15:55:33)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11284 (2019‑05‑30 12:01:15)
    Description The specialty of the professional e.g. physiotherapy, oncology, mental health etc
    Rationale PractitionerRole.speciality
    Operationalization NHS data dictionary - Activity treatment function code
    Value Domain
    Property
    max length
    3
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Professional identifier 0 … 1
    prsb03-dataelement-12104
    Id prsb03-dataelement-12104 (2019‑05‑31 15:55:33)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11285 (2019‑05‑30 12:02:46)
    Description Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.
    Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
    Operationalization NHS data dictionary : - Professional registration identifier
    Value Domain
    Property
    max length
    32
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Organisation 0 … 1
    prsb03-dataelement-12105
    Id prsb03-dataelement-12105 (2019‑05‑31 15:55:33)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
    Description The name of the organisation the professional works for.
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Contact details 0 … 1
    prsb03-dataelement-12106
    Id prsb03-dataelement-12106 (2019‑05‑31 15:55:33)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11287 (2019‑05‑30 12:18:13)
    Description Contact details of the professional
    Rationale Practitioner.telecom

    PractitionerRole.telecom

    Organisation.telcom
    Operationalization NHS data dictionary - UK phone number
    Value Domain
    Property
    max length
    35
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Location 0 … 1
    prsb03-dataelement-10159
    Id prsb03-dataelement-10159 (2018‑10‑31)
    Cardinality 0 … 1
    Description The location where the investigation took place.
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Coded location 0 … 1
    prsb03-dataelement-13725
    Id prsb03-dataelement-13725 (2020‑09‑16 12:46:40)
    Cardinality 0 … 1
    Description The coded value for location
    Operationalization NHS data dictionary : Organisation data service
    Value Domain
    Property
    min length max length
    3 5
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Free text 0 … 1
    prsb03-dataelement-13726
    Id prsb03-dataelement-13726 (2020‑09‑16 13:10:32)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
    Description Free text field to be used if no code is available
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Investigation 1 … 1 Mandatory
    prsb03-dataelement-10160
    Id prsb03-dataelement-10160 (2018‑10‑31)
    Cardinality 1 … 1 Mandatory
    Context
    It is important to record why test have been done and where relevant, who is going to follow up (i.e. GP or hospital). Follow up should be recorded in the plan and requested actions section.
    Investigations carried out where results are not yet available should be recorded in this section.

    Description The investigation performed.
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Coded value 0 … 1
    prsb03-dataelement-13525
    Id prsb03-dataelement-13525 (2020‑09‑04 14:11:36)
    Cardinality 0 … 1
    Description The coded value for investigation
    Operationalization SNOMED CT: - <71388002 |Procedure (procedure)|

    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Free text 0 … 1
    prsb03-dataelement-13526
    Id prsb03-dataelement-13526 (2020‑09‑04 14:22:43)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
    Description Free text field to be used if no code is available
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Investigation result 0 … 1
    prsb03-dataelement-10161
    Id prsb03-dataelement-10161 (2018‑10‑31)
    Cardinality 0 … 1
    Context This section includes details of the investigation results.  Systems should allow copies of reports, scans, images related to the investigation results to be shared with the record. It allows for results in either structured format (e.g. blood tests) or unstructured format (e.g. genetic test with the result as a report).  One or other of these should be used for the result. Investigation results received from laboratories may be imported into this section.
    • Only important or relevant results should be included, ie those that the clinician wants to communicate. This is to reduce the risk of overload of irrelevant information.
    • This can be a difficult decision to make and so consideration should be given to ways that a clinician could be helped in this task.

    Description For each investigation, the result of the investigation. This can include a report which may have results for multiple tests.
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Coded value 0 … 1
    prsb03-dataelement-13527
    Id prsb03-dataelement-13527 (2020‑09‑04 14:25:41)
    Cardinality 0 … 1
    Description The coded value for investigation results
    Operationalization SNOMED CT:- <404684003 |Clinical finding (finding)| OR <243796009 |Situation with explicit context (situation)|

    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Free text 0 … 1
    prsb03-dataelement-13528
    Id prsb03-dataelement-13528 (2020‑09‑04 14:29:50)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
    Description Free text field to be used if no code is available
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Structured investigation result 0 … 1
    prsb03-dataelement-12415
    Id prsb03-dataelement-12415 (2019‑06‑07 16:21:34)
    Cardinality 0 … 1
    Description A structured set of information for each investigation result.
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Value 0 … 1
    prsb03-dataelement-12416
    Id prsb03-dataelement-12416 (2019‑06‑07 16:22:08)
    Cardinality 0 … 1
    Description The value of the investigation result.
    Operationalization Numeric
    Value Domain
    Property
    max length
    10
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Units of measure 0 … 1
    prsb03-dataelement-12417
    Id prsb03-dataelement-12417 (2019‑06‑07 16:23:50)
    Cardinality 0 … 1
    Description The units of the investigation result.
    Operationalization UCUM code
    Value Domain
    Property
    max length
    10
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Reference ranges 0 … 1
    prsb03-dataelement-12418
    Id prsb03-dataelement-12418 (2019‑06‑07 16:24:48)
    Cardinality 0 … 1
    Description The reference range for the investigation result.
    Operationalization Free text
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Abnormal indicator 0 … 1
    prsb03-dataelement-12419
    Id prsb03-dataelement-12419 (2019‑06‑07 16:26:00)
    Cardinality 0 … 1
    Description Indicator if the investigation is abnormal.
    Operationalization Abnormal or Normal
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Person completing record 0 … 1
    prsb03-dataelement-12107
    Id prsb03-dataelement-12107 (2019‑05‑31 15:55:48)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
    Description Details of the person completing the record.
    Relationship
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Name 0 … 1
    prsb03-dataelement-12108
    Id prsb03-dataelement-12108 (2019‑05‑31 15:56:17)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11290 (2019‑05‑30 12:25:39)
    Description The name of the person completing the record.
    Relationship
    Rationale Composition.author.Practitioner.name
    Operationalization Free text.
    Value Domain
    Property
    max length
    70
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Role 0 … 1
    prsb03-dataelement-12109
    Id prsb03-dataelement-12109 (2019‑05‑31 15:56:17)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
    Description The organisational role of the person completing record.

    Properties

    FHIR PractitionerRole.code of the practitioner completing the record
    Relationship
    Rationale Composition.author.Practitioner.PractitionerRole.code
    Operationalization FHIR value set :- SDSjobrole
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Grade 0 … 1
    prsb03-dataelement-12110
    Id prsb03-dataelement-12110 (2019‑05‑31 15:56:17)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11292 (2019‑05‑30 12:25:39)
    Description The grade of the person completing the record.
    Relationship
    Rationale PractitionerRole.code
    Operationalization Free text.
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Specialty 0 … 1
    prsb03-dataelement-12111
    Id prsb03-dataelement-12111 (2019‑05‑31 15:56:17)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11293 (2019‑05‑30 12:25:39)
    Description The main specialty of the person completing the record.

    Properties

    FHIR PractitionerRole.specialty
    Relationship
    Rationale PractitionerRole.speciality
    Operationalization NHS data dictionary :- Activity treatment function code
    Value Domain
    Property
    max length
    3
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Organisation 0 … 1
    prsb03-dataelement-12112
    Id prsb03-dataelement-12112 (2019‑05‑31 15:56:17)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
    Description The organisation the person completing the record works for.
    Relationship
    Operationalization NHS data dictionary : - Organisation data service
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Professional identifier 0 … 1
    prsb03-dataelement-12113
    Id prsb03-dataelement-12113 (2019‑05‑31 15:56:17)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11295 (2019‑05‑30 12:25:39)
    Description Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.

    Properties

    FHIR PractitionerRole.Practitioner.identifier (local) Practitioner.identifer (professional)
    Relationship
    Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
    Operationalization NHS data dictionary :- Professional registration identifier
    Value Domain
    Property
    max length
    32
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Date completed 0 … 1
    prsb03-dataelement-12114
    Id prsb03-dataelement-12114 (2019‑05‑31 15:56:17)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11296 (2019‑05‑30 12:25:39)
    Description The date and time the record was completed.
    Relationship
    Rationale Composition.date
    Operationalization Date and time.
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Contact details 0 … 1
    prsb03-dataelement-12115
    Id prsb03-dataelement-12115 (2019‑05‑31 15:56:17)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
    Description Contact details of the person completing the record.

    Properties

    FHIR PractitionerRole.telecom
    Relationship
    Rationale Practitioner.telecom

    PractitionerRole.telecom

    Organisation.telcom
    Operationalization NHS data dictionary : - UK telephone number
    Value Domain
    Property
    max length
    35
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Assessments 0 … 1
    prsb03-dataelement-262
    Id prsb03-dataelement-262 (2018‑10‑31)
    Cardinality 0 … 1
    Description Details of the person's assessments
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Assessments record entry 0 … *
    prsb03-dataelement-11664
    Id prsb03-dataelement-11664 (2019‑05‑30 19:29:51)
    Cardinality 0 … *
    Description This is the assessments record entry. There may be 0 to many record entry/entries under a section. Each record entry is made up of a number of elements or data items.
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Date 0 … 1
    prsb03-dataelement-10763
    Id prsb03-dataelement-10763 (2019‑03‑18 13:51:22)
    Cardinality 0 … 1
    Description The date the assessment was done.
    Relationship
    Operationalization Date and time.
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Location 0 … 1
    prsb03-dataelement-10764
    Id prsb03-dataelement-10764 (2019‑03‑18 13:51:59)
    Cardinality 0 … 1
    Description The location where the assessment was done.
    Relationship
    Operationalization ODS code or free text.
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Coded value 0 … 1
    prsb03-dataelement-13570
    Id prsb03-dataelement-13570 (2020‑09‑07 15:40:22)
    Cardinality 0 … 1
    Description The coded value for location
    Operationalization NHS data dictionary: - Organisation data service
    Value Domain
    Property
    min length max length
    3 5
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Free text 0 … 1
    prsb03-dataelement-13571
    Id prsb03-dataelement-13571 (2020‑09‑07 15:41:51)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
    Description Free text field to be used if no code is available
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Assessment type 0 … 1
    prsb03-dataelement-10822
    Id prsb03-dataelement-10822 (2019‑03‑21 12:55:22)
    Cardinality 0 … 1
    Description The type of the assessment e.g. social care needs assessment.
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Assessment summary 0 … 1
    prsb03-dataelement-10754
    Id prsb03-dataelement-10754 (2019‑03‑07 18:21:12)
    Cardinality 0 … 1
    Description The summary of the assessment
    Operationalization Free text
    Value Domain
    Property
    max length
    250
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Structured assessment 0 … 1
    prsb03-dataelement-10655
    Id prsb03-dataelement-10655 (2018‑11‑13 12:15:56)
    Cardinality 0 … 1
    Description Details of the structured assessment.
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Structured assessment name 0 … 1
    prsb03-dataelement-11751
    Id prsb03-dataelement-11751 (2019‑05‑31 13:52:26)
    Cardinality 0 … 1
    Description Structured assessment name e.g. New York Heart Failure, Glasgow Coma scale, Activities of Daily Living (ADL) etc.
    Operationalization SNOMED CT
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Assessment score 0 … 1
    prsb03-dataelement-10162
    Id prsb03-dataelement-10162 (2018‑10‑31)
    Cardinality 0 … 1
    Description The structured assessment score.
    Operationalization Free text.
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Assessment value 0 … 1
    prsb03-dataelement-10163
    Id prsb03-dataelement-10163 (2018‑10‑31)
    Cardinality 0 … 1
    Description The structured assessment value.
    Operationalization Numeric
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Subscale score 0 … *
    prsb03-dataelement-10169
    Id prsb03-dataelement-10169 (2018‑10‑31)
    Cardinality 0 … *
    Description The subscale score of the structured assessment.
    Operationalization Free text.
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Subscale value 0 … *
    prsb03-dataelement-10170
    Id prsb03-dataelement-10170 (2018‑10‑31)
    Cardinality 0 … *
    Description The subscale value of the structured assessment.
    Operationalization Numeric
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Performing professional 0 … 1
    prsb03-dataelement-12382
    Id prsb03-dataelement-12382 (2019‑06‑03 16:02:23)
    Cardinality 0 … 1
    Description The professional who did the assessment.
    Relationship
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Name 0 … 1
    prsb03-dataelement-12383
    Id prsb03-dataelement-12383 (2019‑06‑03 16:02:46)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
    Description The name of the professional.
    Rationale Practitioner.name
    Operationalization Free text.
    Value Domain
    Property
    max length
    70
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Role 0 … 1
    prsb03-dataelement-12384
    Id prsb03-dataelement-12384 (2019‑06‑03 16:02:46)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11283 (2019‑05‑30 11:58:48)
    Description The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc
    Rationale Practitioner.PractitionerRole.code
    Operationalization FHIR value set :- SDSjobroletype
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Grade 0 … 1
    prsb03-dataelement-12385
    Id prsb03-dataelement-12385 (2019‑06‑03 16:02:46)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
    Description The grade of the professional.
    Rationale PractitionerRole.code
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Speciality 0 … 1
    prsb03-dataelement-12386
    Id prsb03-dataelement-12386 (2019‑06‑03 16:02:46)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11284 (2019‑05‑30 12:01:15)
    Description The specialty of the professional e.g. physiotherapy, oncology, mental health etc
    Rationale PractitionerRole.speciality
    Operationalization NHS data dictionary - Activity treatment function code
    Value Domain
    Property
    max length
    3
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Professional identifier 0 … 1
    prsb03-dataelement-12387
    Id prsb03-dataelement-12387 (2019‑06‑03 16:02:46)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11285 (2019‑05‑30 12:02:46)
    Description Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.
    Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
    Operationalization NHS data dictionary : - Professional registration identifier
    Value Domain
    Property
    max length
    32
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Organisation 0 … 1
    prsb03-dataelement-12388
    Id prsb03-dataelement-12388 (2019‑06‑03 16:02:46)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
    Description The name of the organisation the professional works for.
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Contact details 0 … 1
    prsb03-dataelement-12389
    Id prsb03-dataelement-12389 (2019‑06‑03 16:02:46)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11287 (2019‑05‑30 12:18:13)
    Description Contact details of the professional
    Rationale Practitioner.telecom

    PractitionerRole.telecom

    Organisation.telcom
    Operationalization NHS data dictionary - UK phone number
    Value Domain
    Property
    max length
    35
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Person completing record 0 … 1
    prsb03-dataelement-11752
    Id prsb03-dataelement-11752 (2019‑05‑31 14:08:29)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
    Description Details of the person completing the record.
    Relationship
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Name 0 … 1
    prsb03-dataelement-11753
    Id prsb03-dataelement-11753 (2019‑05‑31 14:08:52)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11290 (2019‑05‑30 12:25:39)
    Description The name of the person completing the record.
    Relationship
    Rationale Composition.author.Practitioner.name
    Operationalization Free text.
    Value Domain
    Property
    max length
    70
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Role 0 … 1
    prsb03-dataelement-11754
    Id prsb03-dataelement-11754 (2019‑05‑31 14:08:52)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
    Description The organisational role of the person completing record.

    Properties

    FHIR PractitionerRole.code of the practitioner completing the record
    Relationship
    Rationale Composition.author.Practitioner.PractitionerRole.code
    Operationalization FHIR value set :- SDSjobrole
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Grade 0 … 1
    prsb03-dataelement-11755
    Id prsb03-dataelement-11755 (2019‑05‑31 14:08:52)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11292 (2019‑05‑30 12:25:39)
    Description The grade of the person completing the record.
    Relationship
    Rationale PractitionerRole.code
    Operationalization Free text.
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Specialty 0 … 1
    prsb03-dataelement-11756
    Id prsb03-dataelement-11756 (2019‑05‑31 14:08:52)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11293 (2019‑05‑30 12:25:39)
    Description The main specialty of the person completing the record.

    Properties

    FHIR PractitionerRole.specialty
    Relationship
    Rationale PractitionerRole.speciality
    Operationalization NHS data dictionary :- Activity treatment function code
    Value Domain
    Property
    max length
    3
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Organisation 0 … 1
    prsb03-dataelement-11757
    Id prsb03-dataelement-11757 (2019‑05‑31 14:08:52)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
    Description The organisation the person completing the record works for.
    Relationship
    Operationalization NHS data dictionary : - Organisation data service
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Professional identifier 0 … 1
    prsb03-dataelement-11758
    Id prsb03-dataelement-11758 (2019‑05‑31 14:08:52)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11295 (2019‑05‑30 12:25:39)
    Description Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.

    Properties

    FHIR PractitionerRole.Practitioner.identifier (local) Practitioner.identifer (professional)
    Relationship
    Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
    Operationalization NHS data dictionary :- Professional registration identifier
    Value Domain
    Property
    max length
    32
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Date completed 0 … 1
    prsb03-dataelement-11759
    Id prsb03-dataelement-11759 (2019‑05‑31 14:08:52)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11296 (2019‑05‑30 12:25:39)
    Description The date and time the record was completed.
    Relationship
    Rationale Composition.date
    Operationalization Date and time.
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Contact details 0 … 1
    prsb03-dataelement-11760
    Id prsb03-dataelement-11760 (2019‑05‑31 14:08:52)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
    Description Contact details of the person completing the record.

    Properties

    FHIR PractitionerRole.telecom
    Relationship
    Rationale Practitioner.telecom

    PractitionerRole.telecom

    Organisation.telcom
    Operationalization NHS data dictionary : - UK telephone number
    Value Domain
    Property
    max length
    35
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Comment 0 … 1
    prsb03-dataelement-10164
    Id prsb03-dataelement-10164 (2018‑10‑31)
    Cardinality 0 … 1
    Description Supporting text may be given regarding the assessment.
    Operationalization Free text
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Risks 0 … 1
    prsb03-dataelement-276
    Id prsb03-dataelement-276 (2018‑10‑31)
    Cardinality 0 … 1
    Context
    The Risks section could potentially contain sensitive information. Therefore sufficient role based access controls should be in place to ensure this information is only shared with those care professionals where there is a need to do so.
    There may be situations where it not advisable to share information in this section with the person to whom it relates. Appropriate policies and technical solutions need to be in place for these situations.
    All information needs to be reviewed on a regular basis, but it is particularly important for this type of information, given its sensitive nature. There must be mechanisms in place to validate the information in this section and for it to be reviewed regularly.
    The peculiarity of risk factors in mental health needs to be taken into consideration i.e. the most important factor in risk is history so information here should not be archived or filtered without careful consideration. 

    Description Details of any risks related to the person.
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Risks to self 0 … *
    prsb03-dataelement-10176
    Id prsb03-dataelement-10176 (2018‑10‑31)
    Cardinality 0 … *
    Description Details of the persons risk to self

    Properties

    FHIR Composition.text
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Start date of risk 0 … 1
    prsb03-dataelement-11893
    Id prsb03-dataelement-11893 (2019‑05‑31 14:50:40)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-10179 (2018‑10‑31)
    Description The start date of the risk.
    Operationalization Date and time
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited once
     
    draft End date of risk 0 … 1
    prsb03-dataelement-11894
    Id prsb03-dataelement-11894 (2019‑05‑31 14:51:05)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-10801 (2019‑03‑20 14:20:23)
    Description The date the risk ended.
    Operationalization Date and time
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited once
     
    draft Risk to self 0 … 1
    prsb03-dataelement-13579
    Id prsb03-dataelement-13579 (2020‑09‑08 11:10:38)
    Cardinality 0 … 1
    Description Risks the person poses to themselves, e.g. suicide, overdose, self-harm, self-neglect.
    Operationalization SNOMED CT: - <281694009 |Finding of at risk (finding)|

    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Location 0 … 1
    prsb03-dataelement-11895
    Id prsb03-dataelement-11895 (2019‑05‑31 14:51:50)
    Cardinality 0 … 1
    Description The location where the risk was identified.
    Relationship
    target Used by one transaction, 0 templates, inherited once
     
    draft Coded value 0 … 1
    prsb03-dataelement-13586
    Id prsb03-dataelement-13586 (2020‑09‑08 12:08:47)
    Cardinality 0 … 1
    Description The coded value for location
    Operationalization NHS data dictionary : - Organisation service code
    Value Domain
    Property
    min length max length
    3 5
    target Used by one transaction, 0 templates, inherited once
     
    draft Free text 0 … 1
    prsb03-dataelement-13587
    Id prsb03-dataelement-13587 (2020‑09‑08 12:09:57)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
    Description Free text field to be used if no code is available
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited once
     
    folder draft Performing professional 0 … 1
    prsb03-dataelement-11896
    Id prsb03-dataelement-11896 (2019‑05‑31 14:52:35)
    Cardinality 0 … 1
    Description The professional who identified the risk.
    Relationship
    target Used by one transaction, 0 templates, inherited once
     
    draft Name 0 … 1
    prsb03-dataelement-11897
    Id prsb03-dataelement-11897 (2019‑05‑31 14:52:54)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
    Description The name of the professional.
    Rationale Practitioner.name
    Operationalization Free text.
    Value Domain
    Property
    max length
    70
    target Used by one transaction, 0 templates, inherited once
     
    draft Role 0 … 1
    prsb03-dataelement-11898
    Id prsb03-dataelement-11898 (2019‑05‑31 14:52:54)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11283 (2019‑05‑30 11:58:48)
    Description The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc
    Rationale Practitioner.PractitionerRole.code
    Operationalization FHIR value set :- SDSjobroletype
    Value Domain
    target Used by one transaction, 0 templates, inherited once
     
    draft Grade 0 … 1
    prsb03-dataelement-11899
    Id prsb03-dataelement-11899 (2019‑05‑31 14:52:54)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
    Description The grade of the professional.
    Rationale PractitionerRole.code
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited once
     
    draft Speciality 0 … 1
    prsb03-dataelement-11900
    Id prsb03-dataelement-11900 (2019‑05‑31 14:52:54)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11284 (2019‑05‑30 12:01:15)
    Description The specialty of the professional e.g. physiotherapy, oncology, mental health etc
    Rationale PractitionerRole.speciality
    Operationalization NHS data dictionary - Activity treatment function code
    Value Domain
    Property
    max length
    3
    target Used by one transaction, 0 templates, inherited once
     
    draft Professional identifier 0 … 1
    prsb03-dataelement-11901
    Id prsb03-dataelement-11901 (2019‑05‑31 14:52:54)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11285 (2019‑05‑30 12:02:46)
    Description Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.
    Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
    Operationalization NHS data dictionary : - Professional registration identifier
    Value Domain
    Property
    max length
    32
    target Used by one transaction, 0 templates, inherited once
     
    folder draft Organisation 0 … 1
    prsb03-dataelement-11902
    Id prsb03-dataelement-11902 (2019‑05‑31 14:52:54)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
    Description The name of the organisation the professional works for.
    target Used by one transaction, 0 templates, inherited once
     
    draft Contact details 0 … 1
    prsb03-dataelement-11903
    Id prsb03-dataelement-11903 (2019‑05‑31 14:52:54)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11287 (2019‑05‑30 12:18:13)
    Description Contact details of the professional
    Rationale Practitioner.telecom

    PractitionerRole.telecom

    Organisation.telcom
    Operationalization NHS data dictionary - UK phone number
    Value Domain
    Property
    max length
    35
    target Used by one transaction, 0 templates, inherited once
     
    folder draft Person completing record 0 … 1
    prsb03-dataelement-11904
    Id prsb03-dataelement-11904 (2019‑05‑31 14:53:05)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
    Description Details of the person completing the record.
    Relationship
    target Used by one transaction, 0 templates, inherited once
     
    draft Name 0 … 1
    prsb03-dataelement-11905
    Id prsb03-dataelement-11905 (2019‑05‑31 14:53:43)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11290 (2019‑05‑30 12:25:39)
    Description The name of the person completing the record.
    Relationship
    Rationale Composition.author.Practitioner.name
    Operationalization Free text.
    Value Domain
    Property
    max length
    70
    target Used by one transaction, 0 templates, inherited once
     
    draft Role 0 … 1
    prsb03-dataelement-11906
    Id prsb03-dataelement-11906 (2019‑05‑31 14:53:43)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
    Description The organisational role of the person completing record.

    Properties

    FHIR PractitionerRole.code of the practitioner completing the record
    Relationship
    Rationale Composition.author.Practitioner.PractitionerRole.code
    Operationalization FHIR value set :- SDSjobrole
    Value Domain
    target Used by one transaction, 0 templates, inherited once
     
    draft Grade 0 … 1
    prsb03-dataelement-11907
    Id prsb03-dataelement-11907 (2019‑05‑31 14:53:43)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11292 (2019‑05‑30 12:25:39)
    Description The grade of the person completing the record.
    Relationship
    Rationale PractitionerRole.code
    Operationalization Free text.
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited once
     
    draft Specialty 0 … 1
    prsb03-dataelement-11908
    Id prsb03-dataelement-11908 (2019‑05‑31 14:53:43)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11293 (2019‑05‑30 12:25:39)
    Description The main specialty of the person completing the record.

    Properties

    FHIR PractitionerRole.specialty
    Relationship
    Rationale PractitionerRole.speciality
    Operationalization NHS data dictionary :- Activity treatment function code
    Value Domain
    Property
    max length
    3
    target Used by one transaction, 0 templates, inherited once
     
    folder draft Organisation 0 … 1
    prsb03-dataelement-11909
    Id prsb03-dataelement-11909 (2019‑05‑31 14:53:43)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
    Description The organisation the person completing the record works for.
    Relationship
    Operationalization NHS data dictionary : - Organisation data service
    target Used by one transaction, 0 templates, inherited once
     
    draft Professional identifier 0 … 1
    prsb03-dataelement-11910
    Id prsb03-dataelement-11910 (2019‑05‑31 14:53:43)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11295 (2019‑05‑30 12:25:39)
    Description Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.

    Properties

    FHIR PractitionerRole.Practitioner.identifier (local) Practitioner.identifer (professional)
    Relationship
    Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
    Operationalization NHS data dictionary :- Professional registration identifier
    Value Domain
    Property
    max length
    32
    target Used by one transaction, 0 templates, inherited once
     
    draft Date completed 0 … 1
    prsb03-dataelement-11911
    Id prsb03-dataelement-11911 (2019‑05‑31 14:53:43)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11296 (2019‑05‑30 12:25:39)
    Description The date and time the record was completed.
    Relationship
    Rationale Composition.date
    Operationalization Date and time.
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited once
     
    draft Contact details 0 … 1
    prsb03-dataelement-11912
    Id prsb03-dataelement-11912 (2019‑05‑31 14:53:43)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
    Description Contact details of the person completing the record.

    Properties

    FHIR PractitionerRole.telecom
    Relationship
    Rationale Practitioner.telecom

    PractitionerRole.telecom

    Organisation.telcom
    Operationalization NHS data dictionary : - UK telephone number
    Value Domain
    Property
    max length
    35
    target Used by one transaction, 0 templates, inherited once
     
    folder draft Risks to others 0 … *
    prsb03-dataelement-10177
    Id prsb03-dataelement-10177 (2018‑10‑31)
    Cardinality 0 … *
    Description Details of the person's risk to others

    Properties

    FHIR Composition.text
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Start date of risk 0 … 1
    prsb03-dataelement-11913
    Id prsb03-dataelement-11913 (2019‑05‑31 14:54:14)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-10179 (2018‑10‑31)
    Description The start date of the risk.
    Operationalization Date and time
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft End date of risk 0 … 1
    prsb03-dataelement-11914
    Id prsb03-dataelement-11914 (2019‑05‑31 14:54:38)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-10801 (2019‑03‑20 14:20:23)
    Description The date the risk ended.
    Operationalization Date and time
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Risks to others 0 … 1
    prsb03-dataelement-13580
    Id prsb03-dataelement-13580 (2020‑09‑08 11:21:20)
    Cardinality 0 … 1
    Description Risks to professionals or others.
    Operationalization SNOMED CT: - <<391155006 |At risk of harming others (finding)|

    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Location 0 … 1
    prsb03-dataelement-11915
    Id prsb03-dataelement-11915 (2019‑05‑31 14:55:04)
    Cardinality 0 … 1
    Description The location where the risk to others was identified.
    Relationship
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Coded value 0 … 1
    prsb03-dataelement-13588
    Id prsb03-dataelement-13588 (2020‑09‑08 12:15:45)
    Cardinality 0 … 1
    Description The coded value for location
    Operationalization NHS data dictionary : - Organisation data service
    Value Domain
    Property
    min length max length
    3 5
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Free text 0 … 1
    prsb03-dataelement-13589
    Id prsb03-dataelement-13589 (2020‑09‑08 12:17:17)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
    Description Free text field to be used if no code is available
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Performing professional 0 … 1
    prsb03-dataelement-11916
    Id prsb03-dataelement-11916 (2019‑05‑31 14:55:39)
    Cardinality 0 … 1
    Description The professional who identifies the risk to others.
    Relationship
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Name 0 … 1
    prsb03-dataelement-11917
    Id prsb03-dataelement-11917 (2019‑05‑31 14:55:55)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
    Description The name of the professional.
    Rationale Practitioner.name
    Operationalization Free text.
    Value Domain
    Property
    max length
    70
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Role 0 … 1
    prsb03-dataelement-11918
    Id prsb03-dataelement-11918 (2019‑05‑31 14:55:55)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11283 (2019‑05‑30 11:58:48)
    Description The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc
    Rationale Practitioner.PractitionerRole.code
    Operationalization FHIR value set :- SDSjobroletype
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Grade 0 … 1
    prsb03-dataelement-11919
    Id prsb03-dataelement-11919 (2019‑05‑31 14:55:55)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
    Description The grade of the professional.
    Rationale PractitionerRole.code
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Speciality 0 … 1
    prsb03-dataelement-11920
    Id prsb03-dataelement-11920 (2019‑05‑31 14:55:55)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11284 (2019‑05‑30 12:01:15)
    Description The specialty of the professional e.g. physiotherapy, oncology, mental health etc
    Rationale PractitionerRole.speciality
    Operationalization NHS data dictionary - Activity treatment function code
    Value Domain
    Property
    max length
    3
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Professional identifier 0 … 1
    prsb03-dataelement-11921
    Id prsb03-dataelement-11921 (2019‑05‑31 14:55:55)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11285 (2019‑05‑30 12:02:46)
    Description Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.
    Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
    Operationalization NHS data dictionary : - Professional registration identifier
    Value Domain
    Property
    max length
    32
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Organisation 0 … 1
    prsb03-dataelement-11922
    Id prsb03-dataelement-11922 (2019‑05‑31 14:55:55)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
    Description The name of the organisation the professional works for.
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Contact details 0 … 1
    prsb03-dataelement-11923
    Id prsb03-dataelement-11923 (2019‑05‑31 14:55:55)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11287 (2019‑05‑30 12:18:13)
    Description Contact details of the professional
    Rationale Practitioner.telecom

    PractitionerRole.telecom

    Organisation.telcom
    Operationalization NHS data dictionary - UK phone number
    Value Domain
    Property
    max length
    35
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Person completing record 0 … 1
    prsb03-dataelement-11924
    Id prsb03-dataelement-11924 (2019‑05‑31 14:56:46)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
    Description Details of the person completing the record.
    Relationship
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Name 0 … 1
    prsb03-dataelement-11925
    Id prsb03-dataelement-11925 (2019‑05‑31 14:57:11)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11290 (2019‑05‑30 12:25:39)
    Description The name of the person completing the record.
    Relationship
    Rationale Composition.author.Practitioner.name
    Operationalization Free text.
    Value Domain
    Property
    max length
    70
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Role 0 … 1
    prsb03-dataelement-11926
    Id prsb03-dataelement-11926 (2019‑05‑31 14:57:11)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
    Description The organisational role of the person completing record.

    Properties

    FHIR PractitionerRole.code of the practitioner completing the record
    Relationship
    Rationale Composition.author.Practitioner.PractitionerRole.code
    Operationalization FHIR value set :- SDSjobrole
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Grade 0 … 1
    prsb03-dataelement-11927
    Id prsb03-dataelement-11927 (2019‑05‑31 14:57:11)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11292 (2019‑05‑30 12:25:39)
    Description The grade of the person completing the record.
    Relationship
    Rationale PractitionerRole.code
    Operationalization Free text.
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Specialty 0 … 1
    prsb03-dataelement-11928
    Id prsb03-dataelement-11928 (2019‑05‑31 14:57:11)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11293 (2019‑05‑30 12:25:39)
    Description The main specialty of the person completing the record.

    Properties

    FHIR PractitionerRole.specialty
    Relationship
    Rationale PractitionerRole.speciality
    Operationalization NHS data dictionary :- Activity treatment function code
    Value Domain
    Property
    max length
    3
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Organisation 0 … 1
    prsb03-dataelement-11929
    Id prsb03-dataelement-11929 (2019‑05‑31 14:57:11)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
    Description The organisation the person completing the record works for.
    Relationship
    Operationalization NHS data dictionary : - Organisation data service
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Professional identifier 0 … 1
    prsb03-dataelement-11930
    Id prsb03-dataelement-11930 (2019‑05‑31 14:57:11)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11295 (2019‑05‑30 12:25:39)
    Description Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.

    Properties

    FHIR PractitionerRole.Practitioner.identifier (local) Practitioner.identifer (professional)
    Relationship
    Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
    Operationalization NHS data dictionary :- Professional registration identifier
    Value Domain
    Property
    max length
    32
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Date completed 0 … 1
    prsb03-dataelement-11931
    Id prsb03-dataelement-11931 (2019‑05‑31 14:57:11)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11296 (2019‑05‑30 12:25:39)
    Description The date and time the record was completed.
    Relationship
    Rationale Composition.date
    Operationalization Date and time.
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Contact details 0 … 1
    prsb03-dataelement-11932
    Id prsb03-dataelement-11932 (2019‑05‑31 14:57:11)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
    Description Contact details of the person completing the record.

    Properties

    FHIR PractitionerRole.telecom
    Relationship
    Rationale Practitioner.telecom

    PractitionerRole.telecom

    Organisation.telcom
    Operationalization NHS data dictionary : - UK telephone number
    Value Domain
    Property
    max length
    35
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Risk from others 0 … *
    prsb03-dataelement-10178
    Id prsb03-dataelement-10178 (2018‑10‑31)
    Cardinality 0 … *
    Description Risks to the person from an identified individual e.g. family member etc.

    Properties

    FHIR Composition.text
    Operationalization Free Text.
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Start date of risk 0 … 1
    prsb03-dataelement-11933
    Id prsb03-dataelement-11933 (2019‑05‑31 14:58:12)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-10179 (2018‑10‑31)
    Description The start date of the risk.
    Operationalization Date and time
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft End date of risk 0 … 1
    prsb03-dataelement-11934
    Id prsb03-dataelement-11934 (2019‑05‑31 14:58:38)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-10801 (2019‑03‑20 14:20:23)
    Description The date the risk ended.
    Operationalization Date and time
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Risk from others 0 … 1
    prsb03-dataelement-13581
    Id prsb03-dataelement-13581 (2020‑09‑08 11:37:50)
    Cardinality 0 … 1
    Description Risks to the person from an identified individual e.g. family member etc.
    Operationalization SNOMED CT: - <281694009 |Finding of at risk (finding)|

    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Location 0 … 1
    prsb03-dataelement-11935
    Id prsb03-dataelement-11935 (2019‑05‑31 14:59:06)
    Cardinality 0 … 1
    Description The location where the risk from others was identified.
    Relationship
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Coded value 0 … 1
    prsb03-dataelement-13590
    Id prsb03-dataelement-13590 (2020‑09‑08 12:21:08)
    Cardinality 0 … 1
    Description The coded value for location
    Operationalization NHS data dictionary : - Organisation data service
    Value Domain
    Property
    min length max length
    3 5
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Free text 0 … 1
    prsb03-dataelement-13591
    Id prsb03-dataelement-13591 (2020‑09‑08 12:22:47)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
    Description Free text field to be used if no code is available
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Performing professional 0 … 1
    prsb03-dataelement-11936
    Id prsb03-dataelement-11936 (2019‑05‑31 14:59:33)
    Cardinality 0 … 1
    Description The professional who identified the risk from others.
    Relationship
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Name 0 … 1
    prsb03-dataelement-11937
    Id prsb03-dataelement-11937 (2019‑05‑31 14:59:53)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
    Description The name of the professional.
    Rationale Practitioner.name
    Operationalization Free text.
    Value Domain
    Property
    max length
    70
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Role 0 … 1
    prsb03-dataelement-11938
    Id prsb03-dataelement-11938 (2019‑05‑31 14:59:53)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11283 (2019‑05‑30 11:58:48)
    Description The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc
    Rationale Practitioner.PractitionerRole.code
    Operationalization FHIR value set :- SDSjobroletype
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Grade 0 … 1
    prsb03-dataelement-11939
    Id prsb03-dataelement-11939 (2019‑05‑31 14:59:53)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
    Description The grade of the professional.
    Rationale PractitionerRole.code
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Speciality 0 … 1
    prsb03-dataelement-11940
    Id prsb03-dataelement-11940 (2019‑05‑31 14:59:53)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11284 (2019‑05‑30 12:01:15)
    Description The specialty of the professional e.g. physiotherapy, oncology, mental health etc
    Rationale PractitionerRole.speciality
    Operationalization NHS data dictionary - Activity treatment function code
    Value Domain
    Property
    max length
    3
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Professional identifier 0 … 1
    prsb03-dataelement-11941
    Id prsb03-dataelement-11941 (2019‑05‑31 14:59:53)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11285 (2019‑05‑30 12:02:46)
    Description Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.
    Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
    Operationalization NHS data dictionary : - Professional registration identifier
    Value Domain
    Property
    max length
    32
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Organisation 0 … 1
    prsb03-dataelement-11942
    Id prsb03-dataelement-11942 (2019‑05‑31 14:59:53)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
    Description The name of the organisation the professional works for.
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Contact details 0 … 1
    prsb03-dataelement-11943
    Id prsb03-dataelement-11943 (2019‑05‑31 14:59:53)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11287 (2019‑05‑30 12:18:13)
    Description Contact details of the professional
    Rationale Practitioner.telecom

    PractitionerRole.telecom

    Organisation.telcom
    Operationalization NHS data dictionary - UK phone number
    Value Domain
    Property
    max length
    35
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Person completing record 0 … 1
    prsb03-dataelement-11944
    Id prsb03-dataelement-11944 (2019‑05‑31 15:00:03)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
    Description Details of the person completing the record.
    Relationship
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Name 0 … 1
    prsb03-dataelement-11945
    Id prsb03-dataelement-11945 (2019‑05‑31 15:00:27)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11290 (2019‑05‑30 12:25:39)
    Description The name of the person completing the record.
    Relationship
    Rationale Composition.author.Practitioner.name
    Operationalization Free text.
    Value Domain
    Property
    max length
    70
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Role 0 … 1
    prsb03-dataelement-11946
    Id prsb03-dataelement-11946 (2019‑05‑31 15:00:27)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
    Description The organisational role of the person completing record.

    Properties

    FHIR PractitionerRole.code of the practitioner completing the record
    Relationship
    Rationale Composition.author.Practitioner.PractitionerRole.code
    Operationalization FHIR value set :- SDSjobrole
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Grade 0 … 1
    prsb03-dataelement-11947
    Id prsb03-dataelement-11947 (2019‑05‑31 15:00:27)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11292 (2019‑05‑30 12:25:39)
    Description The grade of the person completing the record.
    Relationship
    Rationale PractitionerRole.code
    Operationalization Free text.
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Specialty 0 … 1
    prsb03-dataelement-11948
    Id prsb03-dataelement-11948 (2019‑05‑31 15:00:27)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11293 (2019‑05‑30 12:25:39)
    Description The main specialty of the person completing the record.

    Properties

    FHIR PractitionerRole.specialty
    Relationship
    Rationale PractitionerRole.speciality
    Operationalization NHS data dictionary :- Activity treatment function code
    Value Domain
    Property
    max length
    3
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Organisation 0 … 1
    prsb03-dataelement-11949
    Id prsb03-dataelement-11949 (2019‑05‑31 15:00:27)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
    Description The organisation the person completing the record works for.
    Relationship
    Operationalization NHS data dictionary : - Organisation data service
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Professional identifier 0 … 1
    prsb03-dataelement-11950
    Id prsb03-dataelement-11950 (2019‑05‑31 15:00:27)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11295 (2019‑05‑30 12:25:39)
    Description Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.

    Properties

    FHIR PractitionerRole.Practitioner.identifier (local) Practitioner.identifer (professional)
    Relationship
    Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
    Operationalization NHS data dictionary :- Professional registration identifier
    Value Domain
    Property
    max length
    32
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Date completed 0 … 1
    prsb03-dataelement-11951
    Id prsb03-dataelement-11951 (2019‑05‑31 15:00:27)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11296 (2019‑05‑30 12:25:39)
    Description The date and time the record was completed.
    Relationship
    Rationale Composition.date
    Operationalization Date and time.
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Contact details 0 … 1
    prsb03-dataelement-11952
    Id prsb03-dataelement-11952 (2019‑05‑31 15:00:27)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
    Description Contact details of the person completing the record.

    Properties

    FHIR PractitionerRole.telecom
    Relationship
    Rationale Practitioner.telecom

    PractitionerRole.telecom

    Organisation.telcom
    Operationalization NHS data dictionary : - UK telephone number
    Value Domain
    Property
    max length
    35
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Risk of accidents 0 … *
    prsb03-dataelement-10751
    Id prsb03-dataelement-10751 (2019‑03‑07 17:19:00)
    Cardinality 0 … *
    Description Details of the risks the person poses to themselves from accidents.
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Start date of risk 0 … 1
    prsb03-dataelement-11953
    Id prsb03-dataelement-11953 (2019‑05‑31 15:00:58)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-10179 (2018‑10‑31)
    Description The start date of the risk.
    Operationalization Date and time
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft End date of risk 0 … 1
    prsb03-dataelement-11954
    Id prsb03-dataelement-11954 (2019‑05‑31 15:01:29)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-10801 (2019‑03‑20 14:20:23)
    Description The date the risk ended.
    Operationalization Date and time
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Risk of accidents 0 … 1
    prsb03-dataelement-13582
    Id prsb03-dataelement-13582 (2020‑09‑08 11:57:25)
    Cardinality 0 … 1
    Description Risks the person poses to themselves from accidents.
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Location 0 … 1
    prsb03-dataelement-11955
    Id prsb03-dataelement-11955 (2019‑05‑31 15:01:51)
    Cardinality 0 … 1
    Description The location where the risk of accidents was identified.
    Relationship
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Coded value 0 … 1
    prsb03-dataelement-13592
    Id prsb03-dataelement-13592 (2020‑09‑08 12:24:12)
    Cardinality 0 … 1
    Description The coded value for location
    Operationalization NHS data dictionary : - Organisation data service
    Value Domain
    Property
    min length max length
    3 5
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Free text 0 … 1
    prsb03-dataelement-13593
    Id prsb03-dataelement-13593 (2020‑09‑08 12:25:18)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13223 (2020‑07‑08 17:40:09)
    Description Free text field to be used if no coded text available
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Performing professional 0 … 1
    prsb03-dataelement-11956
    Id prsb03-dataelement-11956 (2019‑05‑31 15:02:24)
    Cardinality 0 … 1
    Description The professional who identified the risk of accidents.
    Relationship
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Name 0 … 1
    prsb03-dataelement-11957
    Id prsb03-dataelement-11957 (2019‑05‑31 15:02:41)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
    Description The name of the professional.
    Rationale Practitioner.name
    Operationalization Free text.
    Value Domain
    Property
    max length
    70
    target Used by one transaction, 0 templates, inherited once
     
    draft Role 0 … 1
    prsb03-dataelement-11958
    Id prsb03-dataelement-11958 (2019‑05‑31 15:02:41)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11283 (2019‑05‑30 11:58:48)
    Description The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc
    Rationale Practitioner.PractitionerRole.code
    Operationalization FHIR value set :- SDSjobroletype
    Value Domain
    target Used by one transaction, 0 templates, inherited once
     
    draft Grade 0 … 1
    prsb03-dataelement-11959
    Id prsb03-dataelement-11959 (2019‑05‑31 15:02:41)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
    Description The grade of the professional.
    Rationale PractitionerRole.code
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited once
     
    draft Speciality 0 … 1
    prsb03-dataelement-11960
    Id prsb03-dataelement-11960 (2019‑05‑31 15:02:41)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11284 (2019‑05‑30 12:01:15)
    Description The specialty of the professional e.g. physiotherapy, oncology, mental health etc
    Rationale PractitionerRole.speciality
    Operationalization NHS data dictionary - Activity treatment function code
    Value Domain
    Property
    max length
    3
    target Used by one transaction, 0 templates, inherited once
     
    draft Professional identifier 0 … 1
    prsb03-dataelement-11961
    Id prsb03-dataelement-11961 (2019‑05‑31 15:02:41)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11285 (2019‑05‑30 12:02:46)
    Description Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.
    Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
    Operationalization NHS data dictionary : - Professional registration identifier
    Value Domain
    Property
    max length
    32
    target Used by one transaction, 0 templates, inherited once
     
    folder draft Organisation 0 … 1
    prsb03-dataelement-11962
    Id prsb03-dataelement-11962 (2019‑05‑31 15:02:41)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
    Description The name of the organisation the professional works for.
    target Used by one transaction, 0 templates, inherited once
     
    draft Contact details 0 … 1
    prsb03-dataelement-11963
    Id prsb03-dataelement-11963 (2019‑05‑31 15:02:41)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11287 (2019‑05‑30 12:18:13)
    Description Contact details of the professional
    Rationale Practitioner.telecom

    PractitionerRole.telecom

    Organisation.telcom
    Operationalization NHS data dictionary - UK phone number
    Value Domain
    Property
    max length
    35
    target Used by one transaction, 0 templates, inherited once
     
    folder draft Person completing record 0 … 1
    prsb03-dataelement-11964
    Id prsb03-dataelement-11964 (2019‑05‑31 15:02:51)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
    Description Details of the person completing the record.
    Relationship
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Name 0 … 1
    prsb03-dataelement-11965
    Id prsb03-dataelement-11965 (2019‑05‑31 15:03:12)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11290 (2019‑05‑30 12:25:39)
    Description The name of the person completing the record.
    Relationship
    Rationale Composition.author.Practitioner.name
    Operationalization Free text.
    Value Domain
    Property
    max length
    70
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Role 0 … 1
    prsb03-dataelement-11966
    Id prsb03-dataelement-11966 (2019‑05‑31 15:03:12)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
    Description The organisational role of the person completing record.

    Properties

    FHIR PractitionerRole.code of the practitioner completing the record
    Relationship
    Rationale Composition.author.Practitioner.PractitionerRole.code
    Operationalization FHIR value set :- SDSjobrole
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Grade 0 … 1
    prsb03-dataelement-11967
    Id prsb03-dataelement-11967 (2019‑05‑31 15:03:12)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11292 (2019‑05‑30 12:25:39)
    Description The grade of the person completing the record.
    Relationship
    Rationale PractitionerRole.code
    Operationalization Free text.
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Specialty 0 … 1
    prsb03-dataelement-11968
    Id prsb03-dataelement-11968 (2019‑05‑31 15:03:12)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11293 (2019‑05‑30 12:25:39)
    Description The main specialty of the person completing the record.

    Properties

    FHIR PractitionerRole.specialty
    Relationship
    Rationale PractitionerRole.speciality
    Operationalization NHS data dictionary :- Activity treatment function code
    Value Domain
    Property
    max length
    3
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Organisation 0 … 1
    prsb03-dataelement-11969
    Id prsb03-dataelement-11969 (2019‑05‑31 15:03:12)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
    Description The organisation the person completing the record works for.
    Relationship
    Operationalization NHS data dictionary : - Organisation data service
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Professional identifier 0 … 1
    prsb03-dataelement-11970
    Id prsb03-dataelement-11970 (2019‑05‑31 15:03:12)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11295 (2019‑05‑30 12:25:39)
    Description Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.

    Properties

    FHIR PractitionerRole.Practitioner.identifier (local) Practitioner.identifer (professional)
    Relationship
    Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
    Operationalization NHS data dictionary :- Professional registration identifier
    Value Domain
    Property
    max length
    32
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Date completed 0 … 1
    prsb03-dataelement-11971
    Id prsb03-dataelement-11971 (2019‑05‑31 15:03:12)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11296 (2019‑05‑30 12:25:39)
    Description The date and time the record was completed.
    Relationship
    Rationale Composition.date
    Operationalization Date and time.
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Contact details 0 … 1
    prsb03-dataelement-11972
    Id prsb03-dataelement-11972 (2019‑05‑31 15:03:12)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
    Description Contact details of the person completing the record.

    Properties

    FHIR PractitionerRole.telecom
    Relationship
    Rationale Practitioner.telecom

    PractitionerRole.telecom

    Organisation.telcom
    Operationalization NHS data dictionary : - UK telephone number
    Value Domain
    Property
    max length
    35
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Other risks 0 … *
    prsb03-dataelement-10802
    Id prsb03-dataelement-10802 (2019‑03‑20 14:23:40)
    Cardinality 0 … *
    Description Details of other risks, factors or behaviours relating to the person.
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Start date of risk 0 … 1
    prsb03-dataelement-11973
    Id prsb03-dataelement-11973 (2019‑05‑31 15:03:41)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-10179 (2018‑10‑31)
    Description The start date of the risk.
    Operationalization Date and time
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft End date of risk 0 … 1
    prsb03-dataelement-11974
    Id prsb03-dataelement-11974 (2019‑05‑31 15:04:10)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-10801 (2019‑03‑20 14:20:23)
    Description The date the risk ended.
    Operationalization Date and time
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Other risks 0 … 1
    prsb03-dataelement-13583
    Id prsb03-dataelement-13583 (2020‑09‑08 12:01:56)
    Cardinality 0 … 1
    Description Other risks, factors or behaviours relating to the person.
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Location 0 … 1
    prsb03-dataelement-11975
    Id prsb03-dataelement-11975 (2019‑05‑31 15:04:35)
    Cardinality 0 … 1
    Description The location where the other risks were identified.
    Relationship
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Coded value 0 … 1
    prsb03-dataelement-13594
    Id prsb03-dataelement-13594 (2020‑09‑08 12:26:43)
    Cardinality 0 … 1
    Description The coded value for location
    Operationalization NHS data dictionary : - Organisation data service
    Value Domain
    Property
    min length max length
    3 5
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Free text 0 … 1
    prsb03-dataelement-13595
    Id prsb03-dataelement-13595 (2020‑09‑08 12:27:58)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
    Description Free text field to be used if no code is available
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Performing professional 0 … 1
    prsb03-dataelement-11976
    Id prsb03-dataelement-11976 (2019‑05‑31 15:05:03)
    Cardinality 0 … 1
    Description The professional who identified the other risks.
    Relationship
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Name 0 … 1
    prsb03-dataelement-11977
    Id prsb03-dataelement-11977 (2019‑05‑31 15:05:19)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
    Description The name of the professional.
    Rationale Practitioner.name
    Operationalization Free text.
    Value Domain
    Property
    max length
    70
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Role 0 … 1
    prsb03-dataelement-11978
    Id prsb03-dataelement-11978 (2019‑05‑31 15:05:19)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11283 (2019‑05‑30 11:58:48)
    Description The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc
    Rationale Practitioner.PractitionerRole.code
    Operationalization FHIR value set :- SDSjobroletype
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Grade 0 … 1
    prsb03-dataelement-11979
    Id prsb03-dataelement-11979 (2019‑05‑31 15:05:19)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
    Description The grade of the professional.
    Rationale PractitionerRole.code
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Speciality 0 … 1
    prsb03-dataelement-11980
    Id prsb03-dataelement-11980 (2019‑05‑31 15:05:19)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11284 (2019‑05‑30 12:01:15)
    Description The specialty of the professional e.g. physiotherapy, oncology, mental health etc
    Rationale PractitionerRole.speciality
    Operationalization NHS data dictionary - Activity treatment function code
    Value Domain
    Property
    max length
    3
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Professional identifier 0 … 1
    prsb03-dataelement-11981
    Id prsb03-dataelement-11981 (2019‑05‑31 15:05:19)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11285 (2019‑05‑30 12:02:46)
    Description Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.
    Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
    Operationalization NHS data dictionary : - Professional registration identifier
    Value Domain
    Property
    max length
    32
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Organisation 0 … 1
    prsb03-dataelement-11982
    Id prsb03-dataelement-11982 (2019‑05‑31 15:05:19)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
    Description The name of the organisation the professional works for.
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Contact details 0 … 1
    prsb03-dataelement-11983
    Id prsb03-dataelement-11983 (2019‑05‑31 15:05:19)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11287 (2019‑05‑30 12:18:13)
    Description Contact details of the professional
    Rationale Practitioner.telecom

    PractitionerRole.telecom

    Organisation.telcom
    Operationalization NHS data dictionary - UK phone number
    Value Domain
    Property
    max length
    35
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Person completing record 0 … 1
    prsb03-dataelement-11984
    Id prsb03-dataelement-11984 (2019‑05‑31 15:05:29)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
    Description Details of the person completing the record.
    Relationship
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Name 0 … 1
    prsb03-dataelement-11985
    Id prsb03-dataelement-11985 (2019‑05‑31 15:05:47)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11290 (2019‑05‑30 12:25:39)
    Description The name of the person completing the record.
    Relationship
    Rationale Composition.author.Practitioner.name
    Operationalization Free text.
    Value Domain
    Property
    max length
    70
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Role 0 … 1
    prsb03-dataelement-11986
    Id prsb03-dataelement-11986 (2019‑05‑31 15:05:47)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
    Description The organisational role of the person completing record.

    Properties

    FHIR PractitionerRole.code of the practitioner completing the record
    Relationship
    Rationale Composition.author.Practitioner.PractitionerRole.code
    Operationalization FHIR value set :- SDSjobrole
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Grade 0 … 1
    prsb03-dataelement-11987
    Id prsb03-dataelement-11987 (2019‑05‑31 15:05:47)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11292 (2019‑05‑30 12:25:39)
    Description The grade of the person completing the record.
    Relationship
    Rationale PractitionerRole.code
    Operationalization Free text.
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Specialty 0 … 1
    prsb03-dataelement-11988
    Id prsb03-dataelement-11988 (2019‑05‑31 15:05:47)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11293 (2019‑05‑30 12:25:39)
    Description The main specialty of the person completing the record.

    Properties

    FHIR PractitionerRole.specialty
    Relationship
    Rationale PractitionerRole.speciality
    Operationalization NHS data dictionary :- Activity treatment function code
    Value Domain
    Property
    max length
    3
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Organisation 0 … 1
    prsb03-dataelement-11989
    Id prsb03-dataelement-11989 (2019‑05‑31 15:05:47)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
    Description The organisation the person completing the record works for.
    Relationship
    Operationalization NHS data dictionary : - Organisation data service
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Professional identifier 0 … 1
    prsb03-dataelement-11990
    Id prsb03-dataelement-11990 (2019‑05‑31 15:05:47)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11295 (2019‑05‑30 12:25:39)
    Description Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.

    Properties

    FHIR PractitionerRole.Practitioner.identifier (local) Practitioner.identifer (professional)
    Relationship
    Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
    Operationalization NHS data dictionary :- Professional registration identifier
    Value Domain
    Property
    max length
    32
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Date completed 0 … 1
    prsb03-dataelement-11991
    Id prsb03-dataelement-11991 (2019‑05‑31 15:05:47)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11296 (2019‑05‑30 12:25:39)
    Description The date and time the record was completed.
    Relationship
    Rationale Composition.date
    Operationalization Date and time.
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Contact details 0 … 1
    prsb03-dataelement-11992
    Id prsb03-dataelement-11992 (2019‑05‑31 15:05:47)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
    Description Contact details of the person completing the record.

    Properties

    FHIR PractitionerRole.telecom
    Relationship
    Rationale Practitioner.telecom

    PractitionerRole.telecom

    Organisation.telcom
    Operationalization NHS data dictionary : - UK telephone number
    Value Domain
    Property
    max length
    35
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Allergies and adverse reactions 1 … 1 Mandatory
    prsb03-dataelement-282
    Id prsb03-dataelement-282 (2018‑10‑31)
    Cardinality 1 … 1 Mandatory
    Context
    A full record should be provided of:
    •allergies that the patient tells the hospital about
    •allergic and adverse reactions related to their admission.
    If relevant investigations and observations have been carried out and no allergies or adverse reactions identified then this section should appear in the eDischarge summary with the text “No known allergies or adverse reactions”. If no information is available about allergies or adverse reactions (but allergies or adverse reactions may have been identified), then this section should appear in the eDischarge summary with the text “Information not available”.
    Guidance on good practice recording of allergies and adverse reactions is provided by NICE (https://www.nice.org.uk/guidance/CG183/chapter/1-Recommendations). This relates to end systems rather than the discharge summary, but is included here as its use should improve quality of the information communicated by the hospital.

    Description Allergies and adverse reactions
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Allergies and adverse reactions record entry 0 … *
    prsb03-dataelement-10657
    Id prsb03-dataelement-10657 (2018‑11‑13 12:23:03)
    Cardinality 0 … *
    Description This is a allergies and adverse reactions record entry. There may be 1 to many record entries under a section.

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

    Properties

    FHIR AllergyIntolerance.type
    Rationale AllergyIntolerance.type
    Operationalization FHIR value set :- Allergy, Intolerance
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Causative agent 1 … 1 Mandatory
    prsb03-dataelement-10182
    Id prsb03-dataelement-10182 (2018‑10‑31)
    Cardinality 1 … 1 Mandatory
    Context
    Where there is a diagnostic code for an allergy recorded in the system, the system should trigger an allergy entry. There is a significant risk to patient safety if allergies are not explicitly and prominently displayed. Adverse reactions need to be treated in a similar manner.  
    Adverse reactions other than allergies are mapped to intolerances when communicating them outside the Trust so that the information can be carried within FHIR messages.
    Information about probability of recurrence may be included under allergy text section if this was identified by clinician. There is no longer a separate section for this information. This decision was reached by suppliers and clinicians during FHIR profile mapping.
    Description The agent such as food, drug or substances that has caused or may cause an allergy, intolerance or adverse reaction in this person Or “No known drug allergies or adverse reactions” Or “Information not available”

    Properties

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

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

    Properties

    FHIR dateAsserted
    Rationale Allergyintolerance.asserteddate
    Operationalization Date and time
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Location 0 … 1
    prsb03-dataelement-10846
    Id prsb03-dataelement-10846 (2019‑03‑27 17:04:11)
    Cardinality 0 … 1
    Description Details of where the allergy was identified. Linked to the date of the diagnosis by the professional.
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Coded value 0 … 1
    prsb03-dataelement-13439
    Id prsb03-dataelement-13439 (2020‑08‑19 13:58:37)
    Cardinality 0 … 1
    Description The coded value for location.
    Rationale Location.identifier
    Operationalization NHS data dictionary : - Organisation data service
    Value Domain
    Property
    min length max length
    3 5
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Free text 0 … 1
    prsb03-dataelement-13440
    Id prsb03-dataelement-13440 (2020‑08‑19 14:02:39)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
    Description Free text field to be used if no code is available
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Substance 0 … 1
    prsb03-dataelement-11665
    Id prsb03-dataelement-11665 (2019‑05‑30 20:17:32)
    Cardinality 0 … 1
    Description The substance, or a class of substances, that is considered to be responsible for the adverse reaction.
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Coded value 0 … 1
    prsb03-dataelement-13554
    Id prsb03-dataelement-13554 (2020‑09‑04 16:44:48)
    Cardinality 0 … 1
    Description The coded value for substance
    Rationale AllergyIntolerance. reaction.substance
    Operationalization SNOMED CT : - <105590001 | Substance (substance) | or <373873005 | Pharmaceutical / biologic product (product) |

    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Free text 0 … 1
    prsb03-dataelement-13555
    Id prsb03-dataelement-13555 (2020‑09‑04 16:45:54)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
    Description Free text field to be used if no code is available
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Description of reaction 0 … 1
    prsb03-dataelement-10183
    Id prsb03-dataelement-10183 (2018‑10‑31)
    Cardinality 0 … 1
    Description A description of the manifestation of the allergic or adverse reaction experienced by the person. For example, skin rash.

    Properties

    FHIR AllergyIntolerance.reaction.manifestation AllergyIntolerance.reaction.description
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Coded value 0 … 1
    prsb03-dataelement-13556
    Id prsb03-dataelement-13556 (2020‑09‑04 16:48:37)
    Cardinality 0 … 1
    Description The coded value for description of reaction.
    Rationale AllergyIntolerance.reaction.manifestation
    Operationalization SNOMED CT: - ^1127581000000103 |Health issues simple reference set|
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Free text 0 … 1
    prsb03-dataelement-13557
    Id prsb03-dataelement-13557 (2020‑09‑04 16:51:03)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
    Description Free text field to be used if no code is available
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Onset date 0 … 1
    prsb03-dataelement-13844
    Id prsb03-dataelement-13844 (2020‑12‑29 22:44:39)
    Cardinality 0 … 1
    Description Date and time when manifestations showed e.g could be at home a few days earlier than the contact
    Operationalization Date and time
    Value Domain
    Property
    Timestamp precision
    at least year
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Severity 0 … 1
    prsb03-dataelement-10184
    Id prsb03-dataelement-10184 (2018‑10‑31)
    Cardinality 0 … 1
    Description A description of the severity of the reaction.

    Properties

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

    Properties

    FHIR AllergyIntolerance.verificationStatus
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Coded value 0 … 1
    prsb03-dataelement-13560
    Id prsb03-dataelement-13560 (2020‑09‑04 17:52:26)
    Cardinality 0 … 1
    Description The coded value for certainty.
    Rationale AllergyIntolerance.verificationStatus
    Operationalization FHIR value set : - Certainty
    Value Domain
    target Used by one transaction, 0 templates, inherited once
     
    draft Free text 0 … 1
    prsb03-dataelement-13561
    Id prsb03-dataelement-13561 (2020‑09‑04 17:55:21)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
    Description Free text field to be used if no code is available
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited once
     
    folder draft Route of exposure 0 … 1
    prsb03-dataelement-13856
    Id prsb03-dataelement-13856 (2021‑01‑18 18:45:19)
    Cardinality 0 … 1
    Description The route the person was exposed to the substance
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Coded value 0 … 1
    prsb03-dataelement-13857
    Id prsb03-dataelement-13857 (2021‑01‑18 18:50:12)
    Cardinality 0 … 1
    Description The coded value for route of exposure
    Rationale AllergyIntolerance.exposureroute
    Operationalization SNOMED CT: - ^999000051000001100 |ePrescribing route of administration simple reference set|
    Value Domain
    target Used by one transaction, 0 templates, inherited once
     
    draft Free text 0 … 1
    prsb03-dataelement-13858
    Id prsb03-dataelement-13858 (2021‑01‑18 18:55:02)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13223 (2020‑07‑08 17:40:09)
    Description Free text field to be used if no coded text available
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited once
     
    draft Comment 0 … 1
    prsb03-dataelement-10189
    Id prsb03-dataelement-10189 (2018‑10‑31)
    Cardinality 0 … 1
    Description Any additional comment or clarification about the adverse reaction.
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Evidence 0 … 1
    prsb03-dataelement-10187
    Id prsb03-dataelement-10187 (2018‑10‑31)
    Cardinality 0 … 1
    Description Results of investigations that confirmed the certainty of the diagnosis. Examples might include results of skin prick allergy tests

    Properties

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

    Properties

    FHIR AllergyIntolerance.onset[x]
    Rationale AllergyIntolerance.onset
    Operationalization Date and time
    Value Domain
    Property
    Timestamp precision
    at least year
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Allergy end date 0 … 1
    prsb03-dataelement-14253
    Id prsb03-dataelement-14253 (2021‑03‑04 13:29:34)
    Cardinality 0 … 1
    Description The date the allergy was diagnosed as ended
    Operationalization Date and time 
    Value Domain
    Property
    Timestamp precision
    at least year
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Comment 0 … 1
    prsb03-dataelement-14273
    Id prsb03-dataelement-14273 (2021‑04‑09 11:01:11)
    Cardinality 0 … 1
    Description Any further comments on the person's allergies or adverse reactions.
    Operationalization Free text
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Performing professional 0 … 1
    prsb03-dataelement-12010
    Id prsb03-dataelement-12010 (2019‑05‑31 15:23:59)
    Cardinality 0 … 1
    Description The professional who identified the reaction.
    Relationship
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Name 0 … 1
    prsb03-dataelement-12011
    Id prsb03-dataelement-12011 (2019‑05‑31 15:24:24)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
    Description The name of the professional.
    Rationale Practitioner.name
    Operationalization Free text.
    Value Domain
    Property
    max length
    70
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Role 0 … 1
    prsb03-dataelement-12012
    Id prsb03-dataelement-12012 (2019‑05‑31 15:24:24)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11283 (2019‑05‑30 11:58:48)
    Description The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc
    Rationale Practitioner.PractitionerRole.code
    Operationalization FHIR value set :- SDSjobroletype
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Grade 0 … 1
    prsb03-dataelement-12013
    Id prsb03-dataelement-12013 (2019‑05‑31 15:24:24)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
    Description The grade of the professional.
    Rationale PractitionerRole.code
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Speciality 0 … 1
    prsb03-dataelement-12014
    Id prsb03-dataelement-12014 (2019‑05‑31 15:24:24)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11284 (2019‑05‑30 12:01:15)
    Description The specialty of the professional e.g. physiotherapy, oncology, mental health etc
    Rationale PractitionerRole.speciality
    Operationalization NHS data dictionary - Activity treatment function code
    Value Domain
    Property
    max length
    3
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Professional identifier 0 … 1
    prsb03-dataelement-12015
    Id prsb03-dataelement-12015 (2019‑05‑31 15:24:24)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11285 (2019‑05‑30 12:02:46)
    Description Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.
    Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
    Operationalization NHS data dictionary : - Professional registration identifier
    Value Domain
    Property
    max length
    32
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Organisation 0 … 1
    prsb03-dataelement-12016
    Id prsb03-dataelement-12016 (2019‑05‑31 15:24:24)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
    Description The name of the organisation the professional works for.
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Contact details 0 … 1
    prsb03-dataelement-12017
    Id prsb03-dataelement-12017 (2019‑05‑31 15:24:24)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11287 (2019‑05‑30 12:18:13)
    Description Contact details of the professional
    Rationale Practitioner.telecom

    PractitionerRole.telecom

    Organisation.telcom
    Operationalization NHS data dictionary - UK phone number
    Value Domain
    Property
    max length
    35
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Person completing record 0 … 1
    prsb03-dataelement-12018
    Id prsb03-dataelement-12018 (2019‑05‑31 15:24:36)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
    Description Details of the person completing the record.
    Relationship
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Name 0 … 1
    prsb03-dataelement-12019
    Id prsb03-dataelement-12019 (2019‑05‑31 15:24:56)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11290 (2019‑05‑30 12:25:39)
    Description The name of the person completing the record.
    Relationship
    Rationale Composition.author.Practitioner.name
    Operationalization Free text.
    Value Domain
    Property
    max length
    70
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Role 0 … 1
    prsb03-dataelement-12020
    Id prsb03-dataelement-12020 (2019‑05‑31 15:24:56)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
    Description The organisational role of the person completing record.

    Properties

    FHIR PractitionerRole.code of the practitioner completing the record
    Relationship
    Rationale Composition.author.Practitioner.PractitionerRole.code
    Operationalization FHIR value set :- SDSjobrole
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Grade 0 … 1
    prsb03-dataelement-12021
    Id prsb03-dataelement-12021 (2019‑05‑31 15:24:56)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11292 (2019‑05‑30 12:25:39)
    Description The grade of the person completing the record.
    Relationship
    Rationale PractitionerRole.code
    Operationalization Free text.
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Specialty 0 … 1
    prsb03-dataelement-12022
    Id prsb03-dataelement-12022 (2019‑05‑31 15:24:56)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11293 (2019‑05‑30 12:25:39)
    Description The main specialty of the person completing the record.

    Properties

    FHIR PractitionerRole.specialty
    Relationship
    Rationale PractitionerRole.speciality
    Operationalization NHS data dictionary :- Activity treatment function code
    Value Domain
    Property
    max length
    3
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Organisation 0 … 1
    prsb03-dataelement-12023
    Id prsb03-dataelement-12023 (2019‑05‑31 15:24:56)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
    Description The organisation the person completing the record works for.
    Relationship
    Operationalization NHS data dictionary : - Organisation data service
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Professional identifier 0 … 1
    prsb03-dataelement-12024
    Id prsb03-dataelement-12024 (2019‑05‑31 15:24:56)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11295 (2019‑05‑30 12:25:39)
    Description Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.

    Properties

    FHIR PractitionerRole.Practitioner.identifier (local) Practitioner.identifer (professional)
    Relationship
    Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
    Operationalization NHS data dictionary :- Professional registration identifier
    Value Domain
    Property
    max length
    32
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Date completed 0 … 1
    prsb03-dataelement-12025
    Id prsb03-dataelement-12025 (2019‑05‑31 15:24:56)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11296 (2019‑05‑30 12:25:39)
    Description The date and time the record was completed.
    Relationship
    Rationale Composition.date
    Operationalization Date and time.
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Contact details 0 … 1
    prsb03-dataelement-12026
    Id prsb03-dataelement-12026 (2019‑05‑31 15:24:56)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
    Description Contact details of the person completing the record.

    Properties

    FHIR PractitionerRole.telecom
    Relationship
    Rationale Practitioner.telecom

    PractitionerRole.telecom

    Organisation.telcom
    Operationalization NHS data dictionary : - UK telephone number
    Value Domain
    Property
    max length
    35
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Medications and medical devices 0 … 1
    prsb03-dataelement-636
    Id prsb03-dataelement-636 (2018‑10‑31)
    Cardinality 0 … 1
    Context
    The discharge summary provides a statement of the medication the patient should be taking following discharge. Often it also functions as a prescription/request for those drugs, and some or all of them may be dispensed/supplied by the hospital pharmacy based on how much the patient already has.
    The medications section allows for using structured dose and timing information that is machine readable to facilitate the reading and transfer of medications information between systems and providers of care, through the structured dose direction cluster.  
    Non-technical guidance for medication information has been developed by the PRSB in collaboration with NHS Digital and NHS England and should be referred to alongside the guidance below. See https://theprsb.org/projects-2/digitalmedicationinformation/

    Description Medications and medical devices
    target Used by one transaction, 0 templates, inherited once
     
    folder draft Medication item entry 0 … *
    prsb03-dataelement-10663
    Id prsb03-dataelement-10663 (2018‑11‑13 15:56:21)
    Cardinality 0 … *
    Context
    In UK General Practice systems “product based prescribing” is used, so called because medicinal products are prescribed. An example of this is: “Furosemide 40 mg tablets, take 2 at 8am”.
    In contrast Hospital systems often use “dose based prescribing” which is not dependent on using any particular product but starts with a drug name and then links this to a dose amount and a dose frequency. The same example as above but expressed as dose based prescription would be:“Furosemide 80mg oral at 8 am”. 
    It can be seen that in product based prescribing the size of the tablet / capsule / inhalation / etc. is usually explicitly stated as part of the product name and that typically the route of administration is implicit. In contrast, dose based prescribing starts with the drug name and then typically explicitly builds a dose string out of dose amount, route, and dose timing. Both of these prescribing patterns are therefore supported in the Medication item entry of the Discharge summary Medications and medical devices information model.

    It is recommended that the fields in the Medication item entry should be used as follows.
    For Product based prescribing:
    •Medication name: Enter the medicinal product (e.g. “Furosemide 40 mg tablets”). In dm+d terms this would be either Actual Medicinal Product (AMP) or Virtual Medicinal Product (VMP).
    •Dose directions description: Enter the remaining dose direction (e.g. “take 2 at 8 am”). Information about route may also be included in this same text string but is generally omitted.
    For Dose based prescribing:
    •Medication name: Enter the drug name (e.g. “Furosemide”). In dm+d terms this would be Virtual Therapeutic Moiety (VTM).
    •Form: Optional (e.g. “capsules”, “tablets”, “liquid” etc.).
    •Route: Optional (e.g. “oral”, “intraocular”,” intramuscular” etc.).
    •Dose amount: A plain text description of dose amount (e.g. “80 mg”).
    •Dose timing: A plain text description of medication dose frequency (e.g. “once daily”, “at 8 am”).
    •Site and method are other optional fields that may be used.

    Description 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.
    target Used by one transaction, 0 templates, inherited 2 times
     
    folder draft Medication item cluster 0 … 1
    prsb03-dataelement-10664
    Id prsb03-dataelement-10664 (2018‑11‑13 16:25:51)
    Cardinality 0 … 1
    Description Medication item cluster
    target Used by one transaction, 0 templates, inherited 2 times
     
    draft Date 0 … 1
    prsb03-dataelement-10843
    Id prsb03-dataelement-10843 (2019‑03‑27 16:59:52)
    Cardinality 0 … 1
    Description The date on which the medication or medical device was prescribed.
    Operationalization Date and time
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited 3 times
     
    folder draft Location 0 … 1
    prsb03-dataelement-10844
    Id prsb03-dataelement-10844 (2019‑03‑27 17:01:20)
    Cardinality 0 … 1
    Description The location where the medication or the medical device was prescribed.
    target Used by one transaction, 0 templates, inherited 3 times
     
    draft Coded value 0 … 1
    prsb03-dataelement-13620
    Id prsb03-dataelement-13620 (2020‑09‑08 19:05:36)
    Cardinality 0 … 1
    Description The coded value for location
    Operationalization NHS data dictionary : - Organisation data service
    Value Domain
    Property
    min length max length
    3 5
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Free text 0 … 1
    prsb03-dataelement-13621
    Id prsb03-dataelement-13621 (2020‑09‑08 19:07:01)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
    Description Free text field to be used if no code is available
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Performing professional 0 … 1
    prsb03-dataelement-12002
    Id prsb03-dataelement-12002 (2019‑05‑31 15:12:28)
    Cardinality 0 … 1
    Description The professional who prescribed the medication or medical device.
    Relationship
    target Used by one transaction, 0 templates, inherited 3 times
     
    draft Name 0 … 1
    prsb03-dataelement-12003
    Id prsb03-dataelement-12003 (2019‑05‑31 15:12:48)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
    Description The name of the professional.
    Rationale Practitioner.name
    Operationalization Free text.
    Value Domain
    Property
    max length
    70
    target Used by one transaction, 0 templates, inherited 3 times
     
    draft Role 0 … 1
    prsb03-dataelement-12004
    Id prsb03-dataelement-12004 (2019‑05‑31 15:12:48)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11283 (2019‑05‑30 11:58:48)
    Description The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc
    Rationale Practitioner.PractitionerRole.code
    Operationalization FHIR value set :- SDSjobroletype
    Value Domain
    target Used by one transaction, 0 templates, inherited 3 times
     
    draft Grade 0 … 1
    prsb03-dataelement-12005
    Id prsb03-dataelement-12005 (2019‑05‑31 15:12:48)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
    Description The grade of the professional.
    Rationale PractitionerRole.code
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 3 times
     
    draft Speciality 0 … 1
    prsb03-dataelement-12006
    Id prsb03-dataelement-12006 (2019‑05‑31 15:12:48)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11284 (2019‑05‑30 12:01:15)
    Description The specialty of the professional e.g. physiotherapy, oncology, mental health etc
    Rationale PractitionerRole.speciality
    Operationalization NHS data dictionary - Activity treatment function code
    Value Domain
    Property
    max length
    3
    target Used by one transaction, 0 templates, inherited 3 times
     
    draft Professional identifier 0 … 1
    prsb03-dataelement-12007
    Id prsb03-dataelement-12007 (2019‑05‑31 15:12:48)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11285 (2019‑05‑30 12:02:46)
    Description Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.
    Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
    Operationalization NHS data dictionary : - Professional registration identifier
    Value Domain
    Property
    max length
    32
    target Used by one transaction, 0 templates, inherited 3 times
     
    folder draft Organisation 0 … 1
    prsb03-dataelement-12008
    Id prsb03-dataelement-12008 (2019‑05‑31 15:12:48)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
    Description The name of the organisation the professional works for.
    target Used by one transaction, 0 templates, inherited 3 times
     
    draft Contact details 0 … 1
    prsb03-dataelement-12009
    Id prsb03-dataelement-12009 (2019‑05‑31 15:12:48)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-11287 (2019‑05‑30 12:18:13)
    Description Contact details of the professional
    Rationale Practitioner.telecom

    PractitionerRole.telecom

    Organisation.telcom
    Operationalization NHS data dictionary - UK phone number
    Value Domain
    Property
    max length
    35
    target Used by one transaction, 0 templates, inherited 3 times
     
    folder draft Medication name 1 … 1 Mandatory
    prsb03-dataelement-10536
    Id prsb03-dataelement-10536 (2018‑10‑31)
    Cardinality 1 … 1 Mandatory
    Context
    It is very important that a full and accurate summary record of medications (both prescribed and non-prescribed) is contained within the discharge summary. This should include:
    Any medications that were current at the time of admission and which the hospital wants the patient to continue following discharge.
    Any changes made to medication that was current at the time of admission –
    such as changes of dosage.
    Any medications that were current at the time of admission which were discontinued either during the admission or at the time of discharge.
    Any new medications added since admission and which should be continued following discharge.
    The reasons for any of the above (i.e. changes, discontinuations or additions of medication).
    Ideally the above information should be generated semi-automatically from a hospital e-prescribing system such that drug names will be automatically represented by dm+d codes and also as far as possible the appropriate fields for route, dosage amount and dosage timing etc. will be completed. It is however recognised that, at least initially, much of this information will need to be entered manually. Please see section below which outlines the differences between dose based and product based prescribing and which provides guidance as to how the various fields available should be used in each case.
    Description May be generic name or brand name.

    Properties

    FHIR MedicationStatement.medication[x].medicationCodableConcept MedicationStatement.medication[x].medicationReference (see Medication) (Systems should send as much details as they can. dm+d code can be sent as a simple code/description pair using CodeableConcept, or as a detailed medication record)
    target Used by one transaction, 0 templates, inherited 5 times
     
    draft Coded value 0 … 1
    prsb03-dataelement-13622
    Id prsb03-dataelement-13622 (2020‑09‑08 19:15:21)
    Cardinality 0 … 1
    Description The coded value for medication name
    Rationale MedicationStatement.medication[x].medicationCodableConcept

    Operationalization dm+d:- any code from the VTM, VMP, AMP, VMPP and AMPP concept classes
    Value Domain
    target Used by one transaction, 0 templates, inherited once
     
    draft Free text 0 … 1
    prsb03-dataelement-13623
    Id prsb03-dataelement-13623 (2020‑09‑08 19:17:39)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
    Description Free text field to be used if no code is available
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited once
     
    folder draft Form 0 … 1
    prsb03-dataelement-10537
    Id prsb03-dataelement-10537 (2018‑10‑31)
    Cardinality 0 … 1
    Description The form of the medication e.g. capsule, drops, tablet, lotion etc.

    Properties

    FHIR MedicationStatement.medication[x].medicationReference.medication.form (i.e. form is on the medication profile). Where VTM has form specified (coded) it goes here AMP & VMP don't need seperate Form (it is optional to populate) For VTM the form could be in MedicationStatement.dosage.text (as it would be part of a dosage string) i.e. not a seperately specified code
    target Used by one transaction, 0 templates, inherited 4 times
     
    draft Coded value 0 … 1
    prsb03-dataelement-13624
    Id prsb03-dataelement-13624 (2020‑09‑08 19:32:29)
    Cardinality 0 … 1
    Description The coded value for form.
    Operationalization SNOMED CT: - ^999000781000001107 | National Health Service dictionary of medicines and devices dose form simple reference set (foundation metadata concept) |

    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Free text 0 … 1
    prsb03-dataelement-13625
    Id prsb03-dataelement-13625 (2020‑09‑08 19:33:34)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
    Description Free text field to be used if no code is available
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Route 0 … 1
    prsb03-dataelement-10538
    Id prsb03-dataelement-10538 (2018‑10‑31)
    Cardinality 0 … 1
    Description The route by which the medication is administered e.g. oral, IM, IV

    Properties

    FHIR MedicationStatement.dosage.route
    target Used by one transaction, 0 templates, inherited 5 times
     
    draft Coded value 0 … 1
    prsb03-dataelement-13655
    Id prsb03-dataelement-13655 (2020‑09‑08 20:30:38)
    Cardinality 0 … 1
    Description The coded value for route
    Rationale MedicationStatement.dosage.route

    Operationalization SNOMED CT: - ^999000051000001100 |ePrescribing route of administration simple reference set (foundation metadata concept)|
    Value Domain
    target Used by one transaction, 0 templates, inherited once
     
    draft Free text 0 … 1
    prsb03-dataelement-13656
    Id prsb03-dataelement-13656 (2020‑09‑08 20:31:40)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
    Description Free text field to be used if no code is available
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited once
     
    folder draft Site 0 … 1
    prsb03-dataelement-10540
    Id prsb03-dataelement-10540 (2018‑10‑31)
    Cardinality 0 … 1
    Description The anatomical site at which the medication is to be administered.

    Properties

    FHIR MedicationStatement.dosage.site
    target Used by one transaction, 0 templates, inherited 3 times
     
    draft Coded value 0 … 1
    prsb03-dataelement-13657
    Id prsb03-dataelement-13657 (2020‑09‑08 20:33:18)
    Cardinality 0 … 1
    Description The coded value for site
    Rationale MedicationStatement.dosage.site
    Operationalization SNOMED CT: - <442083009 | Anatomical or acquired body structure (body structure) |

    Value Domain
    target Used by one transaction, 0 templates, inherited 2 times
     
    draft Free text 0 … 1
    prsb03-dataelement-13658
    Id prsb03-dataelement-13658 (2020‑09‑08 20:35:42)
    Cardinality 0 … 1
    Description Free text field to be used when code is not available
    Relationship
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 3 times
     
    folder draft Method 0 … 1
    prsb03-dataelement-10541
    Id prsb03-dataelement-10541 (2018‑10‑31)
    Cardinality 0 … 1
    Description The technique or method by which the medication is to be administered.

    Properties

    FHIR MedicationStatement.dosage.method
    target Used by one transaction, 0 templates, inherited 3 times
     
    draft Over the counter medication flag 0 … 1
    prsb03-dataelement-13379
    Id prsb03-dataelement-13379 (2020‑08‑10 16:51:27)
    Cardinality 0 … 1
    Description Indicates if the medication or device is acquired without a prescription i.e. got by the person over the counter
    Operationalization Flag : - Yes or No
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Structured dose direction cluster 0 … 1
    prsb03-dataelement-11639
    Id prsb03-dataelement-11639 (2019‑05‑30 17:40:22)
    Cardinality 0 … 1
    Context Technical guidance for implementing the structured dose and timing in Fast Healthcare Interoperable Resource (FHIR) messaging is available from NHS Digital  https://developer.nhs.uk/apis/dose-syntax-implementation/.
    When sharing Dose duration direction, the following examples are provided to clarify definitions for two of the coded text items which appear similar. In both cases, these directions are not an absolute instruction. They are: 
    •‘continue medication indefinitely’ - ongoing treatment planned for example when starting daily aspirin or a statin. There will be circumstances where you would stop them such as a GI bleed. 
    •‘do not discontinue’ refers to medication where suddenly stopping could be dangerous, for example the abrupt withdrawal of long-term steroids.

    Description 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.
    target Used by one transaction, 0 templates, inherited 3 times
     
    folder draft Structured dose amount 0 … 1
    prsb03-dataelement-10554
    Id prsb03-dataelement-10554 (2018‑10‑31)
    Cardinality 0 … 1
    Context Quantity may be expressed as the duration, eg number of days, or the number of items, eg tablets, inhalers etc supplied. The days prescribed/supplied should be recorded as a numeric value under the element ‘dose directions duration’. The quantity should be recorded as a textual value eg 30 tablets, 2 inhalers, etc. under medication quantity Whether the quantity is that prescribed or dispensed should also be recorded in the discharge summary.
    Description 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
    target Used by one transaction, 0 templates, inherited 3 times
     
    draft Structured dose timing 0 … 1
    prsb03-dataelement-10555
    Id prsb03-dataelement-10555 (2018‑10‑31)
    Cardinality 0 … 1
    Description 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
    Rationale MedicationStatement.dosage.timing
    Operationalization Numeric
    Value Domain
    target Used by one transaction, 0 templates, inherited 3 times
     
    draft Dose direction duration 0 … 1
    prsb03-dataelement-10548
    Id prsb03-dataelement-10548 (2018‑10‑31)
    Cardinality 0 … 1
    Description 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

    Properties

    FHIR For coded information use MedicationStatement.dosage.additionalInstruction If no codes exist use MedicationStatement.dosage.additionalInstruction CodeableConcept.text Duration goes in MedicationStatement.effective[x].effectivePeriod 12/01/2018 MS.dosage.timing.bounds create another option "boundsCodeableConcept" to hold Continue Indef; Do not disconue; Stop When course complete MS.dosage.timing.bounds.duration to hold the duration For primary care always in dosage string
    Operationalization Numeric
    Value Domain
    target Used by one transaction, 0 templates, inherited 3 times
     
    draft Dose directions description 0 … 1
    prsb03-dataelement-10544
    Id prsb03-dataelement-10544 (2018‑10‑31)
    Cardinality 0 … 1
    Description 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”.

    Properties

    FHIR MedicationStatement.dosage.text
    Rationale MedicationStatement.dosage.text
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 4 times
     
    draft Additional instructions 0 … 1
    prsb03-dataelement-10545
    Id prsb03-dataelement-10545 (2018‑10‑31)
    Cardinality 0 … 1
    Description 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.

    Properties

    FHIR Specific patient instruction use MedicationStatement.dosage.patientInstruction For narrative instructions (e.g. monitoring, pain, prevention) use MedicationStatement.note For dispensing instructions (EPS narrative) use MedicationRequest.note (intent "order" or "plan")
    Rationale MedicationStatement.dosage.additionalInstruction
    Operationalization FHIR value set : - Additional instruction
    Value Domain
    target Used by one transaction, 0 templates, inherited 3 times
     
    folder draft Course details cluster 0 … 1
    prsb03-dataelement-10561
    Id prsb03-dataelement-10561 (2018‑10‑31)
    Cardinality 0 … 1
    Description Details of the overall course of medication.
    target Used by one transaction, 0 templates, inherited 3 times
     
    draft Course status 0 … 1
    prsb03-dataelement-10666
    Id prsb03-dataelement-10666 (2018‑11‑13 16:47:55)
    Cardinality 0 … 1
    Description The status of this prescription.
    Operationalization FHIR value set : - Medication status
      Value Domain
      target Used by one transaction, 0 templates, inherited 3 times
       
      draft Indication 0 … 1
      prsb03-dataelement-10546
      Id prsb03-dataelement-10546 (2018‑10‑31)
      Cardinality 0 … 1
      Description Reason for medication being prescribed, where known.

      Properties

      FHIR MedicationStatement.reasonCode
      Operationalization Free text
      Value Domain
      Property
      max length
      150
      target Used by one transaction, 0 templates, inherited 3 times
       
      draft Start date/time 0 … 1
      prsb03-dataelement-10667
      Id prsb03-dataelement-10667 (2018‑11‑13 16:49:22)
      Cardinality 0 … 1
      Description The date and/or time that the medication course should begin.
      Operationalization Date and time
      Value Domain
      Property
      Timestamp precision
      at least day, month and year, hour and minute
      target Used by one transaction, 0 templates, inherited 3 times
       
      draft End date/time 0 … 1
      prsb03-dataelement-10557
      Id prsb03-dataelement-10557 (2018‑10‑31)
      Cardinality 0 … 1
      Description The date and/or time that the medication course should finish.
      Operationalization Date and time
      Value Domain
      Property
      Timestamp precision
      at least day, month and year, hour and minute
      target Used by one transaction, 0 templates, inherited 3 times
       
      draft Link to indication record 0 … 1
      prsb03-dataelement-10668
      Id prsb03-dataelement-10668 (2018‑11‑13 16:59:09)
      Cardinality 0 … 1
      Description A link to the record which contains the indication for this medication order.
      Operationalization Free text with URL
      Value Domain
      Property
      max length
      150
      target Used by one transaction, 0 templates, inherited 3 times
       
      draft Comment/recommendation 0 … 1
      prsb03-dataelement-10547
      Id prsb03-dataelement-10547 (2018‑10‑31)
      Cardinality 0 … 1
      Description 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 recommendations

      Properties

      FHIR [JH] This will be dropped from the PRSB information model, as conflicts with description above
      Operationalization Free text
      Value Domain
      Property
      max length
      150
      target Used by one transaction, 0 templates, inherited 3 times
       
      folder draft Medication change summary cluster 0 … 1
      prsb03-dataelement-10568
      Id prsb03-dataelement-10568 (2018‑10‑31)
      Cardinality 0 … 1
      Description Records the changes made to medication.
      target Used by one transaction, 0 templates, inherited 3 times
       
      draft Status 0 … 1
      prsb03-dataelement-10669
      Id prsb03-dataelement-10669 (2018‑11‑13 17:00:50)
      Cardinality 0 … 1
      Description The nature of any change made to the medication.
      Operationalization FHIR value set : Medication status
        Value Domain
        target Used by one transaction, 0 templates, inherited 3 times
         
        draft Indication 0 … 1
        prsb03-dataelement-10670
        Id prsb03-dataelement-10670 (2018‑11‑13 17:02:07)
        Cardinality 0 … 1
        Description Reason for change in medication, e.g. sub-therapeutic dose, person intolerant.
        Operationalization
        SNOMED CT:- ^1127601000000107 | Healthcare matters simple reference set (foundation metadata concept) |
        Value Domain
        target Used by one transaction, 0 templates, inherited 3 times
         
        draft Date of change 0 … 1
        prsb03-dataelement-10671
        Id prsb03-dataelement-10671 (2018‑11‑13 17:03:03)
        Cardinality 0 … 1
        Description The date of the change - addition, or amendment
        Rationale ExtensionUKCoreMedicationDosageLastChanged

        Operationalization Date and time
        Value Domain
        Property
        Timestamp precision
        at least day, month and year, hour and minute
        target Used by one transaction, 0 templates, inherited 3 times
         
        draft Description of amendment 0 … 1
        prsb03-dataelement-10672
        Id prsb03-dataelement-10672 (2018‑11‑13 17:03:42)
        Cardinality 0 … 1
        Context
        Any alteration to a medication that might require a change to the GP prescription should be communicated to the GP with the status ‘amended’. Amended generally means changes in VTM and, where relevant, dose. Changes in form or strength should also be communicated where clinically relevant.
        Changes should be recorded in a structured way where possible. Changes in medication can be structured where the medication history was recorded electronically and the system can automatically recognise changes. For clinical safety, an automatic assessment of change would have to compare the exact medication statement(s) on admission and discharge for all drugs with the same VTM (erring on the side of marking a medication as a change if unsure). To match up corresponding medications between two lists for automatic reconciliation would be using the underlying VTM. Then the algorithm could compare the individual prescriptions and determine if there are any changes (this may include change from single to multiple statements for the same VTM and vice versa). The OPENeP system has a user interface to do this (http://www.marand.com/thinkmeds/).
        Hospitals are required to use the Summary Care Record (SCR) for admission medication history, but for hospitals without electronic medication records reconciliation would need to be a manual process.
        If the admission is short (e.g. surgical daycase) and detailed medicines reconciliation hasn’t taken place, on-going medications that the patient is already taking may be omitted from the discharge summary. In this case, the discharge summary should make it clear that any medications listed may not be the only medications that the patient takes. In practice this is often done with a statement of ‘no changes to patient’s regular or pre-admission medication’.

        Description Where a change is made to the medication i.e. one drug stopped and another started or eg dose, frequency or route is changed.
        Operationalization Free text
        Value Domain
        Property
        max length
        150
        target Used by one transaction, 0 templates, inherited 3 times
         
        draft Total dose daily quantity 0 … 1
        prsb03-dataelement-10665
        Id prsb03-dataelement-10665 (2018‑11‑13 16:44:41)
        Cardinality 0 … 1
        Description 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.
        Operationalization Free text
        Value Domain
        target Used by one transaction, 0 templates, inherited 3 times
         
        folder draft Person completing record 0 … 1
        prsb03-dataelement-11993
        Id prsb03-dataelement-11993 (2019‑05‑31 15:11:27)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
        Description Details of the person completing the record.
        Relationship
        target Used by one transaction, 0 templates, inherited 3 times
         
        draft Name 0 … 1
        prsb03-dataelement-11994
        Id prsb03-dataelement-11994 (2019‑05‑31 15:12:02)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11290 (2019‑05‑30 12:25:39)
        Description The name of the person completing the record.
        Relationship
        Rationale Composition.author.Practitioner.name
        Operationalization Free text.
        Value Domain
        Property
        max length
        70
        target Used by one transaction, 0 templates, inherited 3 times
         
        draft Role 0 … 1
        prsb03-dataelement-11995
        Id prsb03-dataelement-11995 (2019‑05‑31 15:12:02)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
        Description The organisational role of the person completing record.

        Properties

        FHIR PractitionerRole.code of the practitioner completing the record
        Relationship
        Rationale Composition.author.Practitioner.PractitionerRole.code
        Operationalization FHIR value set :- SDSjobrole
        Value Domain
        target Used by one transaction, 0 templates, inherited 3 times
         
        draft Grade 0 … 1
        prsb03-dataelement-11996
        Id prsb03-dataelement-11996 (2019‑05‑31 15:12:02)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11292 (2019‑05‑30 12:25:39)
        Description The grade of the person completing the record.
        Relationship
        Rationale PractitionerRole.code
        Operationalization Free text.
        Value Domain
        Property
        max length
        150
        target Used by one transaction, 0 templates, inherited 3 times
         
        draft Specialty 0 … 1
        prsb03-dataelement-11997
        Id prsb03-dataelement-11997 (2019‑05‑31 15:12:02)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11293 (2019‑05‑30 12:25:39)
        Description The main specialty of the person completing the record.

        Properties

        FHIR PractitionerRole.specialty
        Relationship
        Rationale PractitionerRole.speciality
        Operationalization NHS data dictionary :- Activity treatment function code
        Value Domain
        Property
        max length
        3
        target Used by one transaction, 0 templates, inherited 3 times
         
        folder draft Organisation 0 … 1
        prsb03-dataelement-11998
        Id prsb03-dataelement-11998 (2019‑05‑31 15:12:02)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
        Description The organisation the person completing the record works for.
        Relationship
        Operationalization NHS data dictionary : - Organisation data service
        target Used by one transaction, 0 templates, inherited 3 times
         
        draft Professional identifier 0 … 1
        prsb03-dataelement-11999
        Id prsb03-dataelement-11999 (2019‑05‑31 15:12:02)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11295 (2019‑05‑30 12:25:39)
        Description Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.

        Properties

        FHIR PractitionerRole.Practitioner.identifier (local) Practitioner.identifer (professional)
        Relationship
        Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
        Operationalization NHS data dictionary :- Professional registration identifier
        Value Domain
        Property
        max length
        32
        target Used by one transaction, 0 templates, inherited 3 times
         
        draft Date completed 0 … 1
        prsb03-dataelement-12000
        Id prsb03-dataelement-12000 (2019‑05‑31 15:12:02)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11296 (2019‑05‑30 12:25:39)
        Description The date and time the record was completed.
        Relationship
        Rationale Composition.date
        Operationalization Date and time.
        Value Domain
        Property
        Timestamp precision
        at least day, month and year, hour and minute
        target Used by one transaction, 0 templates, inherited 3 times
         
        draft Contact details 0 … 1
        prsb03-dataelement-12001
        Id prsb03-dataelement-12001 (2019‑05‑31 15:12:02)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
        Description Contact details of the person completing the record.

        Properties

        FHIR PractitionerRole.telecom
        Relationship
        Rationale Practitioner.telecom

        PractitionerRole.telecom

        Organisation.telcom
        Operationalization NHS data dictionary : - UK telephone number
        Value Domain
        Property
        max length
        35
        target Used by one transaction, 0 templates, inherited 3 times
         
        folder draft Medical devices entry 0 … *
        prsb03-dataelement-10583
        Id prsb03-dataelement-10583 (2018‑10‑31)
        Cardinality 0 … *
        Description Medical devices
        target Used by one transaction, 0 templates, inherited 2 times
         
        draft Medical device 0 … 1
        prsb03-dataelement-10673
        Id prsb03-dataelement-10673 (2018‑11‑13 17:10:15)
        Cardinality 0 … 1
        Context
        A medical device is defined in the standard as ‘any medical device that isn't prescribed’. Please refer to the  NHS data dictionary for a further description and examples of medical devices. Further guidance can be found from the Medicines and Healthcare Products Regulatory Agency (MHRA).
        Whilst medical devices that are prescribable in primary care are generally well represented in dm+d, there are other kinds of devices used in hospital care. While these may well be codified in SNOMED CT or in some other proprietary coding scheme they will generally not be prescribable in primary care. The following rules apply ONLY for a hospital system which uses dm+d. When entering information about medications and devices into the discharge summary the following rules should be applied:
        • Any medication item or medical device that can be dm+d coded (both prescribed and non-prescribed) should be entered as a ‘medication item’ entry. Changes and reasons for change can be also handled here.
        • Where any admission medication has been discontinued this should be entered using the ‘medication discontinued’ entry
        • Where a medical device has no dm+d code then this should be represented as text using the ‘medical devices’ record entry.

        Description Any medical device that isn't prescribed.
        Operationalization Free text
        Value Domain
        Property
        max length
        150
        target Used by one transaction, 0 templates, inherited 2 times
         
        draft Comments 0 … 1
        prsb03-dataelement-11280
        Id prsb03-dataelement-11280 (2019‑05‑29 17:47:02)
        Cardinality 0 … 1
        Context Implementation guidance
        Description Any information regarding the medical device.
        Operationalization Free text
        Value Domain
        Property
        max length
        150
        target Used by one transaction, 0 templates, inherited 2 times
         
        folder draft Medication discontinued entry 0 … *
        prsb03-dataelement-10576
        Id prsb03-dataelement-10576 (2018‑10‑31)
        Cardinality 0 … *
        Description Medication discontinued entry
        target Used by one transaction, 0 templates, inherited 2 times
         
        folder draft Name of discontinued medication 1 … 1 Mandatory
        prsb03-dataelement-10577
        Id prsb03-dataelement-10577 (2018‑10‑31)
        Cardinality 1 … 1 Mandatory
        Description The name of the medication or medical device being discontinued
        target Used by one transaction, 0 templates, inherited 2 times
         
        draft Coded value 0 … 1
        prsb03-dataelement-13659
        Id prsb03-dataelement-13659 (2020‑09‑08 20:57:52)
        Cardinality 0 … 1
        Description The coded value for medication name
        Operationalization
        dm+d:- any code from the VTM, VMP, AMP, VMPP and AMPP concept classes
        Value Domain
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Free text 0 … 1
        prsb03-dataelement-13660
        Id prsb03-dataelement-13660 (2020‑09‑08 20:58:40)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-13229 (2020‑07‑15 19:30:33)
        Description Amount of vaccine administered.
        Relationship
        Operationalization Free text
        Value Domain
        Property
        max length
        150
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Status 1 … 1 Mandatory
        prsb03-dataelement-12472
        Id prsb03-dataelement-12472 (2019‑06‑25 11:42:23)
        Cardinality 1 … 1 Mandatory
        Description The status of any change made to the medication. MUST CONTAIN STOPPED.
        Operationalization FHIR value set: - Medication status
        Value Domain
        target Used by one transaction, 0 templates, inherited 2 times
         
        draft Indication 0 … 1
        prsb03-dataelement-10579
        Id prsb03-dataelement-10579 (2018‑10‑31)
        Cardinality 0 … 1
        Description The clinical indication for any changes in medication status
        Operationalization
        SNOMED CT:- ^1127601000000107 | Healthcare matters simple reference set (foundation metadata concept) |
        Value Domain
        target Used by one transaction, 0 templates, inherited 3 times
         
        draft Date of change 0 … 1
        prsb03-dataelement-10580
        Id prsb03-dataelement-10580 (2018‑10‑31)
        Cardinality 0 … 1
        Description The date of the discontinuation
        Operationalization Date and time
        Value Domain
        Property
        Timestamp precision
        at least day, month and year, hour and minute
        target Used by one transaction, 0 templates, inherited 2 times
         
        draft Comment 0 … 1
        prsb03-dataelement-10582
        Id prsb03-dataelement-10582 (2018‑10‑31)
        Cardinality 0 … 1
        Description Any additional comment about the discontinuation or amendment.
        Operationalization Free text
        Value Domain
        Property
        max length
        150
        target Used by one transaction, 0 templates, inherited 2 times
         
        folder draft Information and advice given 0 … 1
        prsb03-dataelement-315
        Id prsb03-dataelement-315 (2018‑10‑31)
        Cardinality 0 … 1
        Description Information and advice given
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Information and advice given 0 … 1
        prsb03-dataelement-10215
        Id prsb03-dataelement-10215 (2018‑10‑31)
        Cardinality 0 … 1
        Context
        In some instances health care professionals may want to communicate to the GP specific information and advice which was given to the patient. It is important that this is concise and is only information which it is pertinent for the GP to be aware of.
        Where patients are provided with literature (e.g. pamphlets) there is no need to provide details of the information contained in the literature e.g simply state that the patient was provided with a pamphlet.
        The default is that patients (or their designated carer or guardian where applicable) should get a copy of the discharge summary. Where this is not possible an explanation should be provided in the clinical summary.

        notice There is an open issue with this item:
        Description

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

        Properties

        FHIR Free text only
        Operationalization Free text
        Value Domain
        Property
        max length
        150
        target Used by one transaction, 0 templates, inherited 0 times
         
        folder draft Distribution list 0 … 1
        prsb03-dataelement-330
        Id prsb03-dataelement-330 (2018‑10‑31)
        Cardinality 0 … 1
        Description Distribution list
        target Used by one transaction, 0 templates, inherited 0 times
         
        folder draft Distribution list record entry 0 … *
        prsb03-dataelement-10660
        Id prsb03-dataelement-10660 (2018‑11‑13 13:21:33)
        Cardinality 0 … *
        Context
        This should be a list of people that the discharge summary is being sent to, as the patient and GP need to know where it is being sent.
        Where local systems are capable of doing so, they may use this information to trigger the message to be sent.
        Consideration should be given to sending copy discharge summaries to recipients by secure email where they are unable to receive a structured message, e.g. care homes, community pharmacies. The PRSB has provided guidance on use of secure email.
        Who exactly should receive a copy of a discharge summary will be situation and service specific and should be agreed in a trading agreement with each participating organisation, e.g. whether the copy goes to generic mailbox or to an individual.

        Description This is a Distribution list record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Name 0 … 1
        prsb03-dataelement-10230
        Id prsb03-dataelement-10230 (2018‑10‑31)
        Cardinality 0 … 1
        Description The name of the person the communication is to be sent to, this can be a person or professional.

        Properties

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

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

        Properties

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

        Properties

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

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

        Properties

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

        Properties

        FHIR Organization.name
        Operationalization Free text
        Value Domain
        Property
        max length
        150
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Relationship 0 … 1
        prsb03-dataelement-13793
        Id prsb03-dataelement-13793 (2020‑11‑02 15:35:45)
        Cardinality 0 … 1
        Description The relationship of the receiver to the person for example, carer or parent
        Relationship
        Operationalization FHIR value set : - Related person
        Value Domain
        target Used by one transaction, 0 templates, inherited 0 times
         
        folder draft Plan and requested actions 0 … 1
        prsb03-dataelement-535
        Id prsb03-dataelement-535 (2018‑10‑31)
        Cardinality 0 … 1
        Context
        This is the treatment plan, following discharge, for the treating teams and clinicians and any actions requested. The plan should make clear who is expected to take responsibility for actions following the encounter, eg the person receiving care or their carer; the GP or another heath care professional. For example, follow up renal function test to be arranged by the GP within two weeks of appointment.

        Description The details of planned investigations, procedures and treatment, and whether this plan has been agreed with the person or their legitimate representative.
        target Used by one transaction, 0 templates, inherited 0 times
         
        folder draft Plan and requested actions record entry 0 … *
        prsb03-dataelement-10661
        Id prsb03-dataelement-10661 (2018‑11‑13 13:38:58)
        Cardinality 0 … *
        Description This is a plan and requested actions record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Date 0 … 1
        prsb03-dataelement-10445
        Id prsb03-dataelement-10445 (2018‑10‑31)
        Cardinality 0 … 1
        Description The date on which the plan and requested actions were prepared.
        Operationalization Date and time
        Value Domain
        Property
        Timestamp precision
        at least day, month and year, hour and minute
        target Used by one transaction, 0 templates, inherited 0 times
         
        folder draft Performing professional 0 … 1
        prsb03-dataelement-12167
        Id prsb03-dataelement-12167 (2019‑05‑31 16:13:42)
        Cardinality 0 … 1
        Description The professional who prepared the plan and requested actions.
        Relationship
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Name 0 … 1
        prsb03-dataelement-12168
        Id prsb03-dataelement-12168 (2019‑05‑31 16:14:03)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
        Description The name of the professional.
        Rationale Practitioner.name
        Operationalization Free text.
        Value Domain
        Property
        max length
        70
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Role 0 … 1
        prsb03-dataelement-12169
        Id prsb03-dataelement-12169 (2019‑05‑31 16:14:03)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11283 (2019‑05‑30 11:58:48)
        Description The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc
        Rationale Practitioner.PractitionerRole.code
        Operationalization FHIR value set :- SDSjobroletype
        Value Domain
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Grade 0 … 1
        prsb03-dataelement-12170
        Id prsb03-dataelement-12170 (2019‑05‑31 16:14:03)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
        Description The grade of the professional.
        Rationale PractitionerRole.code
        Operationalization Free text
        Value Domain
        Property
        max length
        150
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Speciality 0 … 1
        prsb03-dataelement-12171
        Id prsb03-dataelement-12171 (2019‑05‑31 16:14:03)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11284 (2019‑05‑30 12:01:15)
        Description The specialty of the professional e.g. physiotherapy, oncology, mental health etc
        Rationale PractitionerRole.speciality
        Operationalization NHS data dictionary - Activity treatment function code
        Value Domain
        Property
        max length
        3
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Professional identifier 0 … 1
        prsb03-dataelement-12172
        Id prsb03-dataelement-12172 (2019‑05‑31 16:14:03)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11285 (2019‑05‑30 12:02:46)
        Description Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.
        Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
        Operationalization NHS data dictionary : - Professional registration identifier
        Value Domain
        Property
        max length
        32
        target Used by one transaction, 0 templates, inherited 0 times
         
        folder draft Organisation 0 … 1
        prsb03-dataelement-12173
        Id prsb03-dataelement-12173 (2019‑05‑31 16:14:03)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
        Description The name of the organisation the professional works for.
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Contact details 0 … 1
        prsb03-dataelement-12174
        Id prsb03-dataelement-12174 (2019‑05‑31 16:14:03)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11287 (2019‑05‑30 12:18:13)
        Description Contact details of the professional
        Rationale Practitioner.telecom

        PractitionerRole.telecom

        Organisation.telcom
        Operationalization NHS data dictionary - UK phone number
        Value Domain
        Property
        max length
        35
        target Used by one transaction, 0 templates, inherited 0 times
         
        folder draft Location 0 … 1
        prsb03-dataelement-10842
        Id prsb03-dataelement-10842 (2019‑03‑27 16:46:10)
        Cardinality 0 … 1
        Description The location where the plan and requested actions were prepared.
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Coded value 0 … 1
        prsb03-dataelement-13684
        Id prsb03-dataelement-13684 (2020‑09‑09 13:11:31)
        Cardinality 0 … 1
        Description The coded value for location
        Operationalization NHS data dictionary : - Organisation data service
        Value Domain
        Property
        min length max length
        3 5
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Free text 0 … 1
        prsb03-dataelement-13685
        Id prsb03-dataelement-13685 (2020‑09‑09 13:12:37)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
        Description Free text field to be used if no code is available
        Operationalization Free text
        Value Domain
        Property
        max length
        150
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Actions for professionals 0 … 1
        prsb03-dataelement-10436
        Id prsb03-dataelement-10436 (2018‑10‑31)
        Cardinality 0 … 1
        Description Including planned investigations, procedures and treatment for a person's identified conditions and priorities. For each action the following should be identified:outcome expectations, including the person’s expectations. A record of the planned and requested actions. May be structured (table), with actions, names, dates, status, location, strategies.
        Operationalization Free text
        Value Domain
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Actions for person or their carer 0 … 1
        prsb03-dataelement-10437
        Id prsb03-dataelement-10437 (2018‑10‑31)
        Cardinality 0 … 1
        Description For each action the following should be identified:outcome expectations, including person’s expectations. A record of the planned and requested actions. May be structured (table), with actions, names, dates, status, location, strategies.
        Operationalization Free text
        Value Domain
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Agreed with the person or their legitimate representative 0 … 1
        prsb03-dataelement-10438
        Id prsb03-dataelement-10438 (2018‑10‑31)
        Cardinality 0 … 1
        Description 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.
        Operationalization Free text
        Value Domain
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Outcome of plan and requested actions 0 … *
        prsb03-dataelement-10950
        Id prsb03-dataelement-10950 (2019‑05‑16 17:36:54)
        Cardinality 0 … *
        Description The details of the outcome of the plan and requested actions.
        Operationalization Free text.
        Value Domain
        target Used by one transaction, 0 templates, inherited 0 times
         
        folder draft Person completing record 0 … 1
        prsb03-dataelement-12175
        Id prsb03-dataelement-12175 (2019‑05‑31 16:15:12)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
        Description Details of the person completing the record.
        Relationship
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Name 0 … 1
        prsb03-dataelement-12176
        Id prsb03-dataelement-12176 (2019‑05‑31 16:15:32)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11290 (2019‑05‑30 12:25:39)
        Description The name of the person completing the record.
        Relationship
        Rationale Composition.author.Practitioner.name
        Operationalization Free text.
        Value Domain
        Property
        max length
        70
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Role 0 … 1
        prsb03-dataelement-12177
        Id prsb03-dataelement-12177 (2019‑05‑31 16:15:32)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
        Description The organisational role of the person completing record.

        Properties

        FHIR PractitionerRole.code of the practitioner completing the record
        Relationship
        Rationale Composition.author.Practitioner.PractitionerRole.code
        Operationalization FHIR value set :- SDSjobrole
        Value Domain
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Grade 0 … 1
        prsb03-dataelement-12178
        Id prsb03-dataelement-12178 (2019‑05‑31 16:15:32)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11292 (2019‑05‑30 12:25:39)
        Description The grade of the person completing the record.
        Relationship
        Rationale PractitionerRole.code
        Operationalization Free text.
        Value Domain
        Property
        max length
        150
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Specialty 0 … 1
        prsb03-dataelement-12179
        Id prsb03-dataelement-12179 (2019‑05‑31 16:15:32)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11293 (2019‑05‑30 12:25:39)
        Description The main specialty of the person completing the record.

        Properties

        FHIR PractitionerRole.specialty
        Relationship
        Rationale PractitionerRole.speciality
        Operationalization NHS data dictionary :- Activity treatment function code
        Value Domain
        Property
        max length
        3
        target Used by one transaction, 0 templates, inherited 0 times
         
        folder draft Organisation 0 … 1
        prsb03-dataelement-12180
        Id prsb03-dataelement-12180 (2019‑05‑31 16:15:32)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
        Description The organisation the person completing the record works for.
        Relationship
        Operationalization NHS data dictionary : - Organisation data service
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Professional identifier 0 … 1
        prsb03-dataelement-12181
        Id prsb03-dataelement-12181 (2019‑05‑31 16:15:32)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11295 (2019‑05‑30 12:25:39)
        Description Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.

        Properties

        FHIR PractitionerRole.Practitioner.identifier (local) Practitioner.identifer (professional)
        Relationship
        Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
        Operationalization NHS data dictionary :- Professional registration identifier
        Value Domain
        Property
        max length
        32
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Date completed 0 … 1
        prsb03-dataelement-12182
        Id prsb03-dataelement-12182 (2019‑05‑31 16:15:32)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11296 (2019‑05‑30 12:25:39)
        Description The date and time the record was completed.
        Relationship
        Rationale Composition.date
        Operationalization Date and time.
        Value Domain
        Property
        Timestamp precision
        at least day, month and year, hour and minute
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Contact details 0 … 1
        prsb03-dataelement-12183
        Id prsb03-dataelement-12183 (2019‑05‑31 16:15:32)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
        Description Contact details of the person completing the record.

        Properties

        FHIR PractitionerRole.telecom
        Relationship
        Rationale Practitioner.telecom

        PractitionerRole.telecom

        Organisation.telcom
        Operationalization NHS data dictionary : - UK telephone number
        Value Domain
        Property
        max length
        35
        target Used by one transaction, 0 templates, inherited 0 times
         
        folder draft Person completing record 1 … 1 Mandatory
        prsb03-dataelement-12605
        Id prsb03-dataelement-12605 (2019‑11‑14 12:34:50)
        Cardinality 1 … 1 Mandatory
        Context This should be the individual responsible for the completion of the discharge summary in the hospital. Others may have contributed to the discharge summary and a record will be maintained in the hospital system.
        Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
        Description Details of the person completing the record.
        Relationship
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Name 1 … 1 Mandatory
        prsb03-dataelement-12606
        Id prsb03-dataelement-12606 (2019‑11‑14 12:35:42)
        Cardinality 1 … 1 Mandatory
        Concept inherits from draft prsb03-dataelement-11290 (2019‑05‑30 12:25:39)
        Description The name of the person completing the record.
        Relationship
        Rationale Composition.author.Practitioner.name
        Operationalization Free text.
        Value Domain
        Property
        max length
        70
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Role 1 … 1 Mandatory
        prsb03-dataelement-12607
        Id prsb03-dataelement-12607 (2019‑11‑14 12:35:42)
        Cardinality 1 … 1 Mandatory
        Concept inherits from draft prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
        Description The organisational role of the person completing record.

        Properties

        FHIR PractitionerRole.code of the practitioner completing the record
        Relationship
        Rationale Composition.author.Practitioner.PractitionerRole.code
        Operationalization FHIR value set :- SDSjobrole
        Value Domain
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Grade 0 … 1
        prsb03-dataelement-12608
        Id prsb03-dataelement-12608 (2019‑11‑14 12:35:42)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11292 (2019‑05‑30 12:25:39)
        Description The grade of the person completing the record.
        Relationship
        Rationale PractitionerRole.code
        Operationalization Free text.
        Value Domain
        Property
        max length
        150
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Specialty 0 … 1
        prsb03-dataelement-12609
        Id prsb03-dataelement-12609 (2019‑11‑14 12:35:42)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11293 (2019‑05‑30 12:25:39)
        Description The main specialty of the person completing the record.

        Properties

        FHIR PractitionerRole.specialty
        Relationship
        Rationale PractitionerRole.speciality
        Operationalization NHS data dictionary :- Activity treatment function code
        Value Domain
        Property
        max length
        3
        target Used by one transaction, 0 templates, inherited 0 times
         
        folder draft Organisation 1 … 1 Mandatory
        prsb03-dataelement-12610
        Id prsb03-dataelement-12610 (2019‑11‑14 12:35:42)
        Cardinality 1 … 1 Mandatory
        Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
        Description The organisation the person completing the record works for.
        Relationship
        Operationalization NHS data dictionary : - Organisation data service
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Professional identifier 0 … 1
        prsb03-dataelement-12611
        Id prsb03-dataelement-12611 (2019‑11‑14 12:35:42)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11295 (2019‑05‑30 12:25:39)
        Description Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.

        Properties

        FHIR PractitionerRole.Practitioner.identifier (local) Practitioner.identifer (professional)
        Relationship
        Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
        Operationalization NHS data dictionary :- Professional registration identifier
        Value Domain
        Property
        max length
        32
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Date completed 1 … 1 Mandatory
        prsb03-dataelement-12612
        Id prsb03-dataelement-12612 (2019‑11‑14 12:35:42)
        Cardinality 1 … 1 Mandatory
        Concept inherits from draft prsb03-dataelement-11296 (2019‑05‑30 12:25:39)
        Description The date and time the record was completed.
        Relationship
        Rationale Composition.date
        Operationalization Date and time.
        Value Domain
        Property
        Timestamp precision
        at least day, month and year, hour and minute
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Contact details 0 … *
        prsb03-dataelement-12613
        Id prsb03-dataelement-12613 (2019‑11‑14 12:35:42)
        Cardinality 0 … *
        Concept inherits from draft prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
        Description Contact details of the person completing the record.

        Properties

        FHIR PractitionerRole.telecom
        Relationship
        Rationale Practitioner.telecom

        PractitionerRole.telecom

        Organisation.telcom
        Operationalization NHS data dictionary : - UK telephone number
        Value Domain
        Property
        max length
        35
        target Used by one transaction, 0 templates, inherited 0 times
         
        folder draft Care and support plan 0 … 1
        prsb03-dataelement-508
        Id prsb03-dataelement-508 (2018‑10‑31)
        Cardinality 0 … 1
        Context
        It should be possible to restrict access to the care and support plan in most cases based on the individual’s consent preferences. However, a data controller may choose to release all or part of the record for legitimate reasons, for example when a person using services is unable to give consent. 
        It should be possible to add attachments or hyperlinks in care and support plans to provide guidance, learning materials, explanatory notes, etc. The date/time of the hyperlink/addition should be included.
        It should be possible to add comments to the plan and to sections in the plan, for example. to identify progress towards a goal (which should have a formal mechanism associated for capturing information). It should also be possible to comment on actions undertaken or suggest changes to actions. Note that adding comments to a plan is not the same as having a dialogue with others involved in the care and support planning process. Separate functionality, e.g. secure messaging would be required for this.

        Description This records the decisions reached during conversation between the individual and health and care professional about future plans and also records progress.
        target Used by one transaction, 0 templates, inherited 0 times
         
        folder draft Strengths 0 … *
        prsb03-dataelement-10419
        Id prsb03-dataelement-10419 (2018‑10‑31)
        Cardinality 0 … *
        Context Definition: Any strengths and assets the person has (i.e. things a person is good at or enjoys doing) relating to their goals and hopes about their health and well-being For example, ‘able to participate in leisure activities’ such as a sport in order to improve health and wellbeing by losing weight.
        Description Any strengths and assets the person has relating to their goals and hopes about their health and well-being.
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Coded value 0 … 1
        prsb03-dataelement-14369
        Id prsb03-dataelement-14369 (2021‑07‑06 12:13:33)
        Cardinality 0 … 1
        Description 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)|
        Operationalization SNOMED CT : - 1127601000000107 | Healthcare matters simple reference set (foundation metadata concept) |
        Value Domain
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Free text 0 … 1
        prsb03-dataelement-14370
        Id prsb03-dataelement-14370 (2021‑07‑06 12:21:31)
        Cardinality 0 … 1
        Description Any supplementary or personalised information that relates to the person's strengths.
        Operationalization Free text
        Value Domain
        target Used by one transaction, 0 templates, inherited 0 times
         
        folder draft Needs, concerns or problems 0 … *
        prsb03-dataelement-10414
        Id prsb03-dataelement-10414 (2018‑10‑31)
        Cardinality 0 … *
        Context
        Needs are defined as health or care deficits identified by the person with their carer(s) or professionals and are the motivations/indications for healthcare activities. Examples of needs could be (e.g.) ‘to dress myself’; ‘to better understand what my various medications are for’; ‘to reduce pain in my knees’.
        Concerns are gathered information to support continuity of care for a person. Concerns can include biological, psychological or social concerns. They may include things the person or carer is concerned about. For example, a person’s concern may be ‘the quality of social housing’; a professional’s concern could be ‘high blood pressure’
        Problems are defined as: A condition that needs addressing and is important for every professional to know about when seeing a person. Problems may include diagnoses (e.g. COPD; diabetes), symptoms (e.g. joint pain; breathlessness), disabilities (e.g. sensory impairments; amputations), health, social and behavioural issues. Problems recorded here may link to the problem list held in a shared care record or GP system for a person using services.

        Description Details of the person needs, concerns or problems
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Coded value 0 … 1
        prsb03-dataelement-14371
        Id prsb03-dataelement-14371 (2021‑07‑06 12:32:19)
        Cardinality 0 … 1
        Description The coded value associated with the person's needs, concerns or problems.
        Operationalization SNOMED CT : -  ^1127581000000103 |Health issues simple reference set|
        Value Domain
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Free text 0 … 1
        prsb03-dataelement-14372
        Id prsb03-dataelement-14372 (2021‑07‑06 12:35:50)
        Cardinality 0 … 1
        Description
        Any supplementary or personalised information that relates to the person's needs, concerns and problems.
        Operationalization Free text 
        Value Domain
        target Used by one transaction, 0 templates, inherited 0 times
         
        folder draft Goals and hopes 0 … *
        prsb03-dataelement-10413
        Id prsb03-dataelement-10413 (2018‑10‑31)
        Cardinality 0 … *
        Context
        Goals and hopes are defined as: 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. For example, ‘weight loss’; smoking cessation’; ‘reducing alcohol intake’; ‘increased sleep’. ‘Goals’ tends to be historically a more medically-used term, whereas ‘hopes’ is used more widely in social care settings.
        It should be possible to include tables (e.g. weekly schedule), diagrams or images (e.g. to illustrate how a person has made progress towards a goal) as well as video and audio clips (i.e. as a communication tool for individuals with complex accessibility requirements).  
        The care and support plan should be structured in a way that supports digital information exchange, with separate sections for strengths, needs and problems which can be linked to specific goals. 
        Description
        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.
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Coded value 0 … 1
        prsb03-dataelement-14373
        Id prsb03-dataelement-14373 (2021‑07‑06 12:55:16)
        Cardinality 0 … 1
        Description 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)|
        Operationalization SNOMED CT : - 413350009|Finding with explicit context|: 246090004|Associated finding|=300798006 |Able to participate in sporting activities (finding)|, 408729009|Finding context|=410518001|Goal|
        Value Domain
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Free text 0 … 1
        prsb03-dataelement-14374
        Id prsb03-dataelement-14374 (2021‑07‑06 12:59:33)
        Cardinality 0 … 1
        Description Any supplementary and personalised information relating to the person's goals, aims and hopes.
        Operationalization Free text
        Value Domain
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Goal importance score 0 … 1
        prsb03-dataelement-14399
        Id prsb03-dataelement-14399 (2021‑07‑07 12:36:16)
        Cardinality 0 … 1
        Context
        It should be possible to prioritise goals, indicating the importance of each goal to the person (e.g. a scale 1 to 10). 
        Each action may also have an associated additional indicator showing how confident the person is to carry it out (e.g. a scale from 1 to 10). 

        Description Assessment of the person's motivations to achieve this goal, how important the goal is to the person on a scale of 1-10.
        Operationalization Numeric scale 1 - 10
        Value Domain
        target Used by one transaction, 0 templates, inherited 0 times
         
        folder draft Actions and activities 0 … *
        prsb03-dataelement-10408
        Id prsb03-dataelement-10408 (2018‑10‑31)
        Cardinality 0 … *
        Description Actions or activities the person or others plan to take to achieve the person's goals and the resources required to do this.

        target Used by one transaction, 0 templates, inherited 0 times
         
        folder draft What 0 … *
        prsb03-dataelement-10675
        Id prsb03-dataelement-10675 (2018‑11‑15 13:33:22)
        Cardinality 0 … *
        Description What the action is and how it is to be carried out?
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Coded value 0 … 1
        prsb03-dataelement-14383
        Id prsb03-dataelement-14383 (2021‑07‑06 15:03:18)
        Cardinality 0 … 1
        Description The coded value for the action.

        Operationalization SNOMED CT : - << 71388002 |Procedure| OR << 129125009 |Procedure with explicit context|
        Value Domain
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Free text 0 … 1
        prsb03-dataelement-14384
        Id prsb03-dataelement-14384 (2021‑07‑06 15:05:00)
        Cardinality 0 … 1
        Description Any supplementary and personalised information for the action.
        Operationalization Free text
        Value Domain
        target Used by one transaction, 0 templates, inherited 0 times
         
        folder draft Who 0 … 1
        prsb03-dataelement-10676
        Id prsb03-dataelement-10676 (2018‑11‑15 13:34:04)
        Cardinality 0 … 1
        Context Each action may also have an associated additional indicator showing how confident the person is to carry it out (e.g. a scale from 1 to 10). 
        Description 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.
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Name 0 … 1
        prsb03-dataelement-14393
        Id prsb03-dataelement-14393 (2021‑07‑06 16:25:18)
        Cardinality 0 … 1
        Description The name of the professional or person carrying out the proposed action.
        Relationship
        Operationalization Free text
        Value Domain
        Property
        max length
        70
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Role 0 … 1
        prsb03-dataelement-14394
        Id prsb03-dataelement-14394 (2021‑07‑06 16:26:27)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-10710 (2018‑12‑04 15:32:09)
        Description The role of the person providing the service.
        Operationalization FHIR values set : - sdsjobrole
        Value Domain
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Team 0 … 1
        prsb03-dataelement-14395
        Id prsb03-dataelement-14395 (2021‑07‑06 16:28:59)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-10355 (2018‑10‑31)
        Description The name of the team.
        Operationalization Free text
        Value Domain
        Property
        max length
        35
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Contact details 0 … 1
        prsb03-dataelement-14396
        Id prsb03-dataelement-14396 (2021‑07‑06 16:30:39)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-10357 (2018‑10‑31)
        Description Contact details of the professional (e.g. telephone number, email address etc.).
        Operationalization Free text
        Value Domain
        Property
        max length
        35
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft When 0 … 1
        prsb03-dataelement-10677
        Id prsb03-dataelement-10677 (2018‑11‑15 13:34:38)
        Cardinality 0 … 1
        Description Planned date, time, or interval, as relevant
        Operationalization Date and time
        Value Domain
        Property
        Timestamp precision
        at least month and year
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Suggested strategies 0 … 1
        prsb03-dataelement-10678
        Id prsb03-dataelement-10678 (2018‑11‑15 13:35:19)
        Cardinality 0 … 1
        Description Suggested strategies for potential problems.
        Operationalization Free text.
        Value Domain
        target Used by one transaction, 0 templates, inherited 0 times
         
        folder draft Status 0 … 1
        prsb03-dataelement-10679
        Id prsb03-dataelement-10679 (2018‑11‑15 13:35:57)
        Cardinality 0 … 1
        Description The status of the action or activity e.g. in progress, done, refused
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Coded value 0 … 1
        prsb03-dataelement-14385
        Id prsb03-dataelement-14385 (2021‑07‑06 15:23:49)
        Cardinality 0 … 1
        Description The coded value for the person's activity status
        Operationalization SNOMED CT : - ^999000081000000105 | Care planning action context values simple reference set (foundation metadata concept) |
        Value Domain
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Free text 0 … 1
        prsb03-dataelement-14386
        Id prsb03-dataelement-14386 (2021‑07‑06 15:25:54)
        Cardinality 0 … 1
        Description Any supplementary or personalised information for the person's activity status
        Operationalization Free text
        Value Domain
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Confidence 0 … 1
        prsb03-dataelement-10680
        Id prsb03-dataelement-10680 (2018‑11‑15 13:54:04)
        Cardinality 0 … 1
        Description How confident the person feels to carry out the action associated to the goal.
        Operationalization Numeric score 1 - 10
        Value Domain
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Date last updated 0 … 1
        prsb03-dataelement-10682
        Id prsb03-dataelement-10682 (2018‑11‑15 13:55:05)
        Cardinality 0 … 1
        Context
        Updates to the care and support plan section may include:
        •Add, edit or archive strengths, needs, concerns or problems. If a strength/need/concern becomes more or less important, then goals may need to be changed, as will associated actions. 
        •Add, edit or archive goals. When a goal is archived it should be possible to also archive the actions associated with it. If the actions are still valid it should be possible to attach them to another goal. 
        •Add, edit or archive actions. Once an action has been completed (i.e. status updated to indicate it has been completed), it should be possible to archive it from the care and support plan. It should be removed from the current active view of the plan, but available to view in previous versions of the plan.  
        •Recording outcomes related to goals. Once a goal has been achieved, it should be possible to archive it from the care and support plan, so that it is removed from the view of the current plan, but available to view in previous versions of the care and support plan.   

        Description Date when action/activity record was last updated
        Operationalization Date and time
        Value Domain
        Property
        Timestamp precision
        at least day, month and year, hour and minute
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Review date 0 … 1
        prsb03-dataelement-10683
        Id prsb03-dataelement-10683 (2018‑11‑15 13:55:47)
        Cardinality 0 … 1
        Description When the action evaluation needs to be reviewed. SNOMED CT tag : - 425268008 | Review of care plan (procedure) |
        Operationalization Date and time.
        Value Domain
        Property
        Timestamp precision
        at least month and year
        target Used by one transaction, 0 templates, inherited 0 times
         
        folder draft Stage goal 0 … *
        prsb03-dataelement-10674
        Id prsb03-dataelement-10674 (2018‑11‑15 13:32:26)
        Cardinality 0 … *
        Description Details of the person's stage goals
        target Used by one transaction, 0 templates, inherited 0 times
         
        folder draft Stage goal 0 … 1
        prsb03-dataelement-14284
        Id prsb03-dataelement-14284 (2021‑06‑10 20:14:27)
        Cardinality 0 … 1
        Description A specific sub-goal that is related to the overall goal as agreed by the person in collaboration with a professional.
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Coded value 0 … 1
        prsb03-dataelement-14375
        Id prsb03-dataelement-14375 (2021‑07‑06 13:03:53)
        Cardinality 0 … 1
        Description The coded expression associated with the person's stage goal.
        Operationalization SNOMED CT : - 413350009|Finding with explicit context|: 246090004|Associated finding|=300798006 |Able to participate in sporting activities (finding)|, 408729009|Finding context|=410518001|Goal|
        Value Domain
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Free text 0 … 1
        prsb03-dataelement-14376
        Id prsb03-dataelement-14376 (2021‑07‑06 13:07:11)
        Cardinality 0 … 1
        Description Any supplementary or personalised information regarding the person's stage goal.
        Operationalization Free text
        Value Domain
        target Used by one transaction, 0 templates, inherited 0 times
         
        folder draft Outcome 0 … 1
        prsb03-dataelement-10681
        Id prsb03-dataelement-10681 (2018‑11‑15 13:54:34)
        Cardinality 0 … 1
        Description The outcome of the stage goal
        Operationalization



        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Coded value 0 … 1
        prsb03-dataelement-14378
        Id prsb03-dataelement-14378 (2021‑07‑06 13:27:55)
        Cardinality 0 … 1
        Description The coded value for the person's stage goal outcome.
        Operationalization SNOMED CT: - ^1127601000000107 |Healthcare matters simple reference set (foundation metadata concept)| 
        Value Domain
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Free text 0 … 1
        prsb03-dataelement-14379
        Id prsb03-dataelement-14379 (2021‑07‑06 13:32:50)
        Cardinality 0 … 1
        Description Any supplementary and personalised information relating to the person's outcome.
        Operationalization Free text
        Value Domain
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Goal status 0 … 1
        prsb03-dataelement-14377
        Id prsb03-dataelement-14377 (2021‑07‑06 13:21:38)
        Cardinality 0 … 1
        Description The status associated with the person's stage goal
        Operationalization SNOMED CT: - ^999000091000000107 | Care planning goal context values simple reference set (foundation metadata concept) |
        Value Domain
        target Used by one transaction, 0 templates, inherited 0 times
         
        folder draft Outcomes 0 … *
        prsb03-dataelement-10416
        Id prsb03-dataelement-10416 (2018‑10‑31)
        Cardinality 0 … *
        Context
        Of particular importance is the link between needs in a care plan and related goals. Each goal must link to specific needs, as well as any actions associated with it. Goals may also have related outcomes.
        The sections associated with goals and actions that are the focus of specific care professionals should be interoperable with the care plan that professional uses for their day to day work.

        Description Outcomes of each of the person’s goals, aims and targets. Includes comments recorded by the person, date and status.
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Coded value 0 … 1
        prsb03-dataelement-14380
        Id prsb03-dataelement-14380 (2021‑07‑06 14:55:09)
        Cardinality 0 … 1
        Description The coded value associated with the person's overall goal outcome
        Operationalization SNOMED CT: -  ^1127601000000107 |Healthcare matters simple reference set (foundation metadata concept)| 
        Value Domain
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Free text 0 … 1
        prsb03-dataelement-14382
        Id prsb03-dataelement-14382 (2021‑07‑06 14:58:53)
        Cardinality 0 … 1
        Description Any supplementary and personalised information relating to the person's goal outcome.
        Operationalization Free text
        Value Domain
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Goal status 0 … 1
        prsb03-dataelement-14400
        Id prsb03-dataelement-14400 (2021‑07‑07 13:14:58)
        Cardinality 0 … 1
        Description The status associated with the person's overall goal.
        Relationship
        Operationalization SNOMED CT: - ^999000091000000107 | Care planning goal context values simple reference set (foundation metadata concept) |
        Value Domain
        target Used by one transaction, 0 templates, inherited 0 times
         
        folder draft Agreed with person or legitimate representative 0 … 1
        prsb03-dataelement-10409
        Id prsb03-dataelement-10409 (2018‑10‑31)
        Cardinality 0 … 1
        Description Indicates whether the plan was discussed and agreed with the person or legitimate representative.
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Person or legitimate representative 0 … 1
        prsb03-dataelement-14322
        Id prsb03-dataelement-14322 (2021‑06‑29 13:05:22)
        Cardinality 0 … 1
        Context
        Agreement of the plan with the person (or representative) should be recorded. If agreement cannot be obtained the reason for this should be documented. 
        Where a person has been unable to agree, due to, for example, lacking mental capacity, actions should be undertaken to maximise capacity and the plan should demonstrate how a person’s rights will be promoted. If a person is unable to consent, a mental capacity assessment should be attempted, and if there is no legal representative a best interest decision made.

        Description Indicates whether the plan was discussed and agreed with the person or legitimate representative
        Operationalization Person or legitimate representative 
        Value Domain
        target Used by one transaction, 0 templates, inherited once
         
        draft Person full name 0 … 1
        prsb03-dataelement-14323
        Id prsb03-dataelement-14323 (2021‑06‑29 13:14:57)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-13801 (2020‑11‑09 17:03:29)
        Description The full name of the person in text representation.
        Rationale Patient.name.text
        Operationalization NHS data dictionary :- Person full name
        Value Domain
        Property
        max length
        70
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Role 0 … 1
        prsb03-dataelement-14324
        Id prsb03-dataelement-14324 (2021‑06‑29 13:16:14)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-12186 (2019‑05‑31 16:19:35)
        Description The role the professional has in relation to the person.
        Relationship
        Operationalization FHIR value set : - sdsjobrole
        Value Domain
        target Used by one transaction, 0 templates, inherited 0 times
         
        folder draft Care funding source 0 … 1
        prsb03-dataelement-10410
        Id prsb03-dataelement-10410 (2018‑10‑31)
        Cardinality 0 … 1
        Context In health and social care there may be different sources of funding (e.g. personal budget/personal health budgets) to meet the aims and goals of the person. The ‘Care Funding Source’ section should only detail the source of the funding so as to support easy resolution where a question about funding arises. The information should not include the details of the funding, which will be held in separate documents.
        Description A reference to the funding source and any conditions or limitations associated.
        target Used by one transaction, 0 templates, inherited once
         
        draft Coded value 0 … 1
        prsb03-dataelement-14391
        Id prsb03-dataelement-14391 (2021‑07‑06 16:12:05)
        Cardinality 0 … 1
        Description The organisation code of the care funding source
        Operationalization NHS data dictionary : - organisation data service
        Value Domain
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Free text 0 … 1
        prsb03-dataelement-14392
        Id prsb03-dataelement-14392 (2021‑07‑06 16:14:07)
        Cardinality 0 … 1
        Description Any further information for the person's care funding source e.g. self funded
        Operationalization Free text 
        Value Domain
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Date this plan was last updated 0 … 1
        prsb03-dataelement-10412
        Id prsb03-dataelement-10412 (2018‑10‑31)
        Cardinality 0 … 1
        Context This information should be automatically retrievable from the system.
        Description This is a record of the date that this care and support plan was last updated.
        Operationalization Date and time
        Value Domain
        Property
        Timestamp precision
        at least day, month and year, hour and minute
        target Used by one transaction, 0 templates, inherited once
         
        draft Other care planning documents 0 … *
        prsb03-dataelement-10415
        Id prsb03-dataelement-10415 (2018‑10‑31)
        Cardinality 0 … *
        Description 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.
        Operationalization Free text.
        Value Domain
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Planned review date/interval 0 … 1
        prsb03-dataelement-10417
        Id prsb03-dataelement-10417 (2018‑10‑31)
        Cardinality 0 … 1
        Description This is the date/interval when this information will next be reviewed. SNOMED CT tag : - 425268008 | Review of care plan (procedure) |
        Operationalization Date and time
        Value Domain
        target Used by one transaction, 0 templates, inherited 0 times
         
        folder draft Responsibility for review 0 … 1
        prsb03-dataelement-10418
        Id prsb03-dataelement-10418 (2018‑10‑31)
        Cardinality 0 … 1
        Description This is a record of who has responsibility for arranging review of this information.
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Name 0 … 1
        prsb03-dataelement-14345
        Id prsb03-dataelement-14345 (2021‑07‑01 20:40:34)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-10352 (2018‑10‑31)
        Description The name of the professional with responsibility for the care of the person.
        Operationalization Free text
        Value Domain
        Property
        max length
        70
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Role 0 … 1
        prsb03-dataelement-14346
        Id prsb03-dataelement-14346 (2021‑07‑01 20:41:35)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-10353 (2018‑10‑31)
        Description 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) etc
        Operationalization FHIR value set : - SDSjobrole
        Value Domain
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Contact details 0 … 1
        prsb03-dataelement-14347
        Id prsb03-dataelement-14347 (2021‑07‑01 20:42:59)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-10357 (2018‑10‑31)
        Description Contact details of the professional (e.g. telephone number, email address etc.).
        Operationalization Free text
        Value Domain
        Property
        max length
        35
        target Used by one transaction, 0 templates, inherited 0 times
         
        folder draft Location 0 … 1
        prsb03-dataelement-12044
        Id prsb03-dataelement-12044 (2019‑05‑31 15:32:03)
        Cardinality 0 … 1
        Description The location where the care and support plan was prepared.
        Relationship
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Coded value 0 … 1
        prsb03-dataelement-13665
        Id prsb03-dataelement-13665 (2020‑09‑08 22:17:08)
        Cardinality 0 … 1
        Description The coded value for location
        Operationalization NHS data dictionary: - Organisation data service
        Value Domain
        Property
        min length max length
        3 5
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Free text 0 … 1
        prsb03-dataelement-13666
        Id prsb03-dataelement-13666 (2020‑09‑08 22:18:17)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-13223 (2020‑07‑08 17:40:09)
        Description Free text field to be used if no coded text available
        Value Domain
        Property
        max length
        150
        target Used by one transaction, 0 templates, inherited 0 times
         
        folder draft Performing professional 0 … 1
        prsb03-dataelement-12027
        Id prsb03-dataelement-12027 (2019‑05‑31 15:30:22)
        Cardinality 0 … 1
        Description The professional who prepared the care and support plan.
        Relationship
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Name 0 … 1
        prsb03-dataelement-12028
        Id prsb03-dataelement-12028 (2019‑05‑31 15:30:50)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
        Description The name of the professional.
        Rationale Practitioner.name
        Operationalization Free text.
        Value Domain
        Property
        max length
        70
        target Used by one transaction, 0 templates, inherited 2 times
         
        draft Role 0 … 1
        prsb03-dataelement-12029
        Id prsb03-dataelement-12029 (2019‑05‑31 15:30:50)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11283 (2019‑05‑30 11:58:48)
        Description The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc
        Rationale Practitioner.PractitionerRole.code
        Operationalization FHIR value set :- SDSjobroletype
        Value Domain
        target Used by one transaction, 0 templates, inherited 2 times
         
        draft Grade 0 … 1
        prsb03-dataelement-12030
        Id prsb03-dataelement-12030 (2019‑05‑31 15:30:50)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
        Description The grade of the professional.
        Rationale PractitionerRole.code
        Operationalization Free text
        Value Domain
        Property
        max length
        150
        target Used by one transaction, 0 templates, inherited 2 times
         
        draft Speciality 0 … 1
        prsb03-dataelement-12031
        Id prsb03-dataelement-12031 (2019‑05‑31 15:30:50)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11284 (2019‑05‑30 12:01:15)
        Description The specialty of the professional e.g. physiotherapy, oncology, mental health etc
        Rationale PractitionerRole.speciality
        Operationalization NHS data dictionary - Activity treatment function code
        Value Domain
        Property
        max length
        3
        target Used by one transaction, 0 templates, inherited 2 times
         
        draft Professional identifier 0 … 1
        prsb03-dataelement-12032
        Id prsb03-dataelement-12032 (2019‑05‑31 15:30:50)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11285 (2019‑05‑30 12:02:46)
        Description Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.
        Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
        Operationalization NHS data dictionary : - Professional registration identifier
        Value Domain
        Property
        max length
        32
        target Used by one transaction, 0 templates, inherited 2 times
         
        folder draft Organisation 0 … 1
        prsb03-dataelement-12033
        Id prsb03-dataelement-12033 (2019‑05‑31 15:30:50)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
        Description The name of the organisation the professional works for.
        target Used by one transaction, 0 templates, inherited 2 times
         
        draft Contact details 0 … 1
        prsb03-dataelement-12034
        Id prsb03-dataelement-12034 (2019‑05‑31 15:30:50)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11287 (2019‑05‑30 12:18:13)
        Description Contact details of the professional
        Rationale Practitioner.telecom

        PractitionerRole.telecom

        Organisation.telcom
        Operationalization NHS data dictionary - UK phone number
        Value Domain
        Property
        max length
        35
        target Used by one transaction, 0 templates, inherited 2 times
         
        folder draft Person completing record 0 … *
        prsb03-dataelement-12035
        Id prsb03-dataelement-12035 (2019‑05‑31 15:31:01)
        Cardinality 0 … *
        Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
        Description Details of the person completing the record.
        Relationship
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Name 0 … 1
        prsb03-dataelement-12036
        Id prsb03-dataelement-12036 (2019‑05‑31 15:31:27)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11290 (2019‑05‑30 12:25:39)
        Description The name of the person completing the record.
        Relationship
        Rationale Composition.author.Practitioner.name
        Operationalization Free text.
        Value Domain
        Property
        max length
        70
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Role 0 … 1
        prsb03-dataelement-12037
        Id prsb03-dataelement-12037 (2019‑05‑31 15:31:27)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
        Description The organisational role of the person completing record.

        Properties

        FHIR PractitionerRole.code of the practitioner completing the record
        Relationship
        Rationale Composition.author.Practitioner.PractitionerRole.code
        Operationalization FHIR value set :- SDSjobrole
        Value Domain
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Grade 0 … 1
        prsb03-dataelement-12038
        Id prsb03-dataelement-12038 (2019‑05‑31 15:31:27)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11292 (2019‑05‑30 12:25:39)
        Description The grade of the person completing the record.
        Relationship
        Rationale PractitionerRole.code
        Operationalization Free text.
        Value Domain
        Property
        max length
        150
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Specialty 0 … 1
        prsb03-dataelement-12039
        Id prsb03-dataelement-12039 (2019‑05‑31 15:31:27)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11293 (2019‑05‑30 12:25:39)
        Description The main specialty of the person completing the record.

        Properties

        FHIR PractitionerRole.specialty
        Relationship
        Rationale PractitionerRole.speciality
        Operationalization NHS data dictionary :- Activity treatment function code
        Value Domain
        Property
        max length
        3
        target Used by one transaction, 0 templates, inherited 0 times
         
        folder draft Organisation 0 … 1
        prsb03-dataelement-12040
        Id prsb03-dataelement-12040 (2019‑05‑31 15:31:27)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
        Description The organisation the person completing the record works for.
        Relationship
        Operationalization NHS data dictionary : - Organisation data service
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Professional identifier 0 … 1
        prsb03-dataelement-12041
        Id prsb03-dataelement-12041 (2019‑05‑31 15:31:27)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11295 (2019‑05‑30 12:25:39)
        Description Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.

        Properties

        FHIR PractitionerRole.Practitioner.identifier (local) Practitioner.identifer (professional)
        Relationship
        Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
        Operationalization NHS data dictionary :- Professional registration identifier
        Value Domain
        Property
        max length
        32
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Date completed 0 … 1
        prsb03-dataelement-12042
        Id prsb03-dataelement-12042 (2019‑05‑31 15:31:27)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11296 (2019‑05‑30 12:25:39)
        Description The date and time the record was completed.
        Relationship
        Rationale Composition.date
        Operationalization Date and time.
        Value Domain
        Property
        Timestamp precision
        at least day, month and year, hour and minute
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Contact details 0 … 1
        prsb03-dataelement-12043
        Id prsb03-dataelement-12043 (2019‑05‑31 15:31:27)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
        Description Contact details of the person completing the record.

        Properties

        FHIR PractitionerRole.telecom
        Relationship
        Rationale Practitioner.telecom

        PractitionerRole.telecom

        Organisation.telcom
        Operationalization NHS data dictionary : - UK telephone number
        Value Domain
        Property
        max length
        35
        target Used by one transaction, 0 templates, inherited 0 times
         
        folder draft Contingency plans 0 … *
        prsb03-dataelement-469
        Id prsb03-dataelement-469 (2018‑10‑31)
        Cardinality 0 … *
        Description These are the things to do and people to contact, should an individual’s health or other circumstances get worse.
        target Used by one transaction, 0 templates, inherited 0 times
         
        folder draft Trigger factors 1 … * Mandatory
        prsb03-dataelement-10375
        Id prsb03-dataelement-10375 (2018‑10‑31)
        Cardinality 1 … * Mandatory
        Description Signs to watch out for that may indicate a significant change in health or other circumstances e.g. feeling agitated
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Coded value 0 … 1
        prsb03-dataelement-14389
        Id prsb03-dataelement-14389 (2021‑07‑06 15:58:34)
        Cardinality 0 … 1
        Description The trigger that leads to instigation of a significant change in health or other circumstances.
        Operationalization SNOMED CT: - ^1127581000000103 | Health issues simple reference set (foundation metadata concept) |
        Value Domain
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Free text 0 … 1
        prsb03-dataelement-14390
        Id prsb03-dataelement-14390 (2021‑07‑06 16:01:56)
        Cardinality 0 … 1
        Description Any free text associated with the person's trigger factor
        Operationalization Free text
        Value Domain
        target Used by one transaction, 0 templates, inherited 0 times
         
        folder draft Contingency plan name 0 … 1
        prsb03-dataelement-10371
        Id prsb03-dataelement-10371 (2018‑10‑31)
        Cardinality 0 … 1
        Context
        Contingency/safety plans are known by other terms depending on care setting. In mental health for example, ‘safety plans’ is a commonly understood term while medically these are more commonly known as ‘Contingency plans’. Please see section 5 for a list of alternative terms.
        Not everyone who has a care and support plan will need a contingency/safety (also known as crisis/emergency/escalation/advance/anticipatory) plan. See the Glossary (section 5) which includes alternative names for care planning concepts in the standard.
        There may be a number of different contingency/safety plans to manage different aspects of health and wellbeing, e.g. diabetes, respiratory, mental health, substance misuse, etc. The plan may cover different scenarios, e.g. mild disruption/issues, through to more severe.  
        Description When the action evaluation needs to be reviewed. 
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Coded value 0 … 1
        prsb03-dataelement-14387
        Id prsb03-dataelement-14387 (2021‑07‑06 15:50:58)
        Cardinality 0 … 1
        Description The coded value for the type of care plan
        Operationalization SNOMED CT: - 999001471000000108 | Care plan type simple reference set (foundation metadata concept) |
        Value Domain
        target Used by one transaction, 0 templates, inherited once
         
        draft Free text 0 … 1
        prsb03-dataelement-14388
        Id prsb03-dataelement-14388 (2021‑07‑06 15:53:06)
        Cardinality 0 … 1
        Description Free text if no coded value is available.
        Operationalization Free text
        Value Domain
        target Used by one transaction, 0 templates, inherited 0 times
         
        folder draft What should happen 0 … *
        prsb03-dataelement-10376
        Id prsb03-dataelement-10376 (2018‑10‑31)
        Cardinality 0 … *
        Context This plan is for those people who have specific and predictable risks associated with their health and wellbeing. It describes how disruptions to the care and support plan should be addressed.
        Description 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.
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Coded value 0 … 1
        prsb03-dataelement-14403
        Id prsb03-dataelement-14403 (2021‑07‑07 13:47:54)
        Cardinality 0 … 1
        Description The coded value for what should happen
        Operationalization
        SNOMED CT : - << 71388002 |Procedure| OR << 129125009 |Procedure with explicit context|
        Value Domain
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Free text 0 … 1
        prsb03-dataelement-14404
        Id prsb03-dataelement-14404 (2021‑07‑07 13:49:20)
        Cardinality 0 … 1
        Description Any supplementary or personalised information regarding what should happen
        Operationalization Free text
        Value Domain
        target Used by one transaction, 0 templates, inherited 0 times
         
        folder draft Who should be contacted 0 … *
        prsb03-dataelement-10377
        Id prsb03-dataelement-10377 (2018‑10‑31)
        Cardinality 0 … *
        Description Who should be contacted in the event of significant problems or deterioration in health or wellbeing. e.g. name, role and contact details.
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Name 0 … 1
        prsb03-dataelement-14405
        Id prsb03-dataelement-14405 (2021‑07‑07 13:56:26)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-10352 (2018‑10‑31)
        Description The name of the professional with responsibility for the care of the person.
        Operationalization Free text
        Value Domain
        Property
        max length
        70
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Role 0 … 1
        prsb03-dataelement-14406
        Id prsb03-dataelement-14406 (2021‑07‑07 13:57:48)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-10353 (2018‑10‑31)
        Description 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) etc
        Operationalization FHIR value set : - SDSjobrole
        Value Domain
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Contact details 0 … 1
        prsb03-dataelement-14407
        Id prsb03-dataelement-14407 (2021‑07‑07 13:59:15)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-10350 (2018‑10‑31)
        Description Contact details of the personal contact (e.g. telephone number, email address etc.)
        Operationalization Free Text
        Value Domain
        Property
        max length
        70
        target Used by one transaction, 0 templates, inherited 0 times
         
        folder draft Agreed with person or legitimate representative 0 … 1
        prsb03-dataelement-10369
        Id prsb03-dataelement-10369 (2018‑10‑31)
        Cardinality 0 … 1
        Context
        It must be possible to create a contingency/safety plan at any time when the individual and those providing care and support identify a need for such a plan. Contingency/safety  plans must be subject to or as a result of an assessment.

        Contingency/safety  plans may include end of life care planning elements. These only form part of an initial conversation and a full end of life care plan should be included separately as an end of life care document.
        Description Indicates whether the plan was discussed and agreed with the person or legitimate representative.
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Person or legitimate representative 0 … 1
        prsb03-dataelement-14339
        Id prsb03-dataelement-14339 (2021‑07‑01 19:11:12)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-14322 (2021‑06‑29 13:05:22)
        Description Indicates whether the plan was discussed and agreed with the person or legitimate representative
        Operationalization Person or legitimate representative 
        Value Domain
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Person full name 0 … 1
        prsb03-dataelement-14340
        Id prsb03-dataelement-14340 (2021‑07‑01 19:13:45)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-13801 (2020‑11‑09 17:03:29)
        Description The full name of the person in text representation.
        Rationale Patient.name.text
        Operationalization NHS data dictionary :- Person full name
        Value Domain
        Property
        max length
        70
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Role 0 … 1
        prsb03-dataelement-14341
        Id prsb03-dataelement-14341 (2021‑07‑01 19:15:23)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-12186 (2019‑05‑31 16:19:35)
        Description The role the professional has in relation to the person.
        Relationship
        Operationalization FHIR value set : - sdsjobrole
        Value Domain
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Date this plan was last updated 0 … 1
        prsb03-dataelement-10372
        Id prsb03-dataelement-10372 (2018‑10‑31)
        Cardinality 0 … 1
        Description The date that this contingency plan was last updated.
        Operationalization Date and time
        Value Domain
        Property
        Timestamp precision
        at least day, month and year, hour and minute
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Planned review date/interval 0 … 1
        prsb03-dataelement-10373
        Id prsb03-dataelement-10373 (2018‑10‑31)
        Cardinality 0 … 1
        Description This is the date/interval when this contingency plan will next be reviewed. SNOMED CT tag : - 425268008 | Review of care plan (procedure) |
        Operationalization Date and time
        Value Domain
        Property
        Timestamp precision
        at least day, month and year, hour and minute
        target Used by one transaction, 0 templates, inherited 0 times
         
        folder draft Responsibility for review 0 … 1
        prsb03-dataelement-10374
        Id prsb03-dataelement-10374 (2018‑10‑31)
        Cardinality 0 … 1
        Description This is who has responsibility for arranging review of this information.
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Name 0 … 1
        prsb03-dataelement-14342
        Id prsb03-dataelement-14342 (2021‑07‑01 19:38:29)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-10352 (2018‑10‑31)
        Description The name of the professional with responsibility for the care of the person.
        Operationalization Free text
        Value Domain
        Property
        max length
        70
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Role 0 … 1
        prsb03-dataelement-14343
        Id prsb03-dataelement-14343 (2021‑07‑01 19:39:46)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-10353 (2018‑10‑31)
        Description 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) etc
        Operationalization FHIR value set : - SDSjobrole
        Value Domain
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Contact details 0 … 1
        prsb03-dataelement-14344
        Id prsb03-dataelement-14344 (2021‑07‑01 19:40:59)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-10357 (2018‑10‑31)
        Description Contact details of the professional (e.g. telephone number, email address etc.).
        Operationalization Free text
        Value Domain
        Property
        max length
        35
        target Used by one transaction, 0 templates, inherited 0 times
         
        folder draft Coping strategies 0 … *
        prsb03-dataelement-13850
        Id prsb03-dataelement-13850 (2021‑01‑08 16:37:56)
        Cardinality 0 … *
        Description Details of coping strategies used
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Coping strategy 0 … 1
        prsb03-dataelement-13851
        Id prsb03-dataelement-13851 (2021‑01‑08 16:45:37)
        Cardinality 0 … 1
        Context
        The ‘Coping Strategies’ element should include details of all coping strategies used in free text. Any tools used to carry out the coping strategy should be included here.
        Coping strategies may need to be regularly updated as it may depend on the stage of recovery the person is at.

        Description 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.
        Operationalization Free text
        Value Domain
        Property
        max length
        150
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Start date 0 … 1
        prsb03-dataelement-13852
        Id prsb03-dataelement-13852 (2021‑01‑08 16:47:18)
        Cardinality 0 … 1
        Description The date when the coping strategy started
        Operationalization Date and time
        Value Domain
        Property
        Timestamp precision
        at least day, month and year, hour and minute
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft End date 0 … 1
        prsb03-dataelement-13853
        Id prsb03-dataelement-13853 (2021‑01‑08 16:48:58)
        Cardinality 0 … 1
        Description The date when the coping strategy ended
        Operationalization Date and time
        Value Domain
        Property
        Timestamp precision
        at least day, month and year, hour and minute
        target Used by one transaction, 0 templates, inherited 0 times
         
        folder draft Relapse indicators / early warning signs 0 … *
        prsb03-dataelement-13854
        Id prsb03-dataelement-13854 (2021‑01‑08 16:49:59)
        Cardinality 0 … *
        Description Details of the relapse indicators for the person. These may also be called 'early warning signs'
        Operationalization

        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Coded value 0 … 1
        prsb03-dataelement-14401
        Id prsb03-dataelement-14401 (2021‑07‑07 13:38:10)
        Cardinality 0 … 1
        Description The coded value for relapse indicators/early warning signs
        Operationalization SNOMED CT : - ^1127601000000107 | Healthcare matters simple reference set (foundation metadata concept) |
        Value Domain
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Free text 0 … 1
        prsb03-dataelement-14402
        Id prsb03-dataelement-14402 (2021‑07‑07 13:42:46)
        Cardinality 0 … 1
        Description Any supplementary or personalised information regarding the relapse indicators/early warning signs
        Operationalization Free text
        Value Domain
        target Used by one transaction, 0 templates, inherited 0 times
         
        folder draft Advance statement 0 … 1
        prsb03-dataelement-10777
        Id prsb03-dataelement-10777 (2019‑03‑19 17:12:20)
        Cardinality 0 … 1
        Description Written requests and preferences made by a person with capacity conveying their wishes, beliefs and values for their future care should they lose capacity.
        Relationship
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Date 0 … 1
        prsb03-dataelement-12267
        Id prsb03-dataelement-12267 (2019‑05‑31 16:39:20)
        Cardinality 0 … 1
        Description The date when the advanced statements was made.
        Relationship
        Operationalization Date and time
        Value Domain
        Property
        Timestamp precision
        at least day, month and year, hour and minute
        target Used by one transaction, 0 templates, inherited 0 times
         
        folder draft Location 0 … 1
        prsb03-dataelement-12268
        Id prsb03-dataelement-12268 (2019‑05‑31 16:39:59)
        Cardinality 0 … 1
        Description The location where the advanced statement was made.
        Relationship
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Coded value 0 … 1
        prsb03-dataelement-13698
        Id prsb03-dataelement-13698 (2020‑09‑09 17:14:46)
        Cardinality 0 … 1
        Description The coded value for location
        Operationalization NHS data dictionary: - Organisation data service
        Value Domain
        Property
        min length max length
        3 5
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Free text 0 … 1
        prsb03-dataelement-13699
        Id prsb03-dataelement-13699 (2020‑09‑09 17:16:21)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
        Description Free text field to be used if no code is available
        Operationalization Free text
        Value Domain
        Property
        max length
        150
        target Used by one transaction, 0 templates, inherited 0 times
         
        folder draft Advance statement 0 … 1
        prsb03-dataelement-13695
        Id prsb03-dataelement-13695 (2020‑09‑09 17:06:33)
        Cardinality 0 … 1
        Description Does the person have an advance statement.
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Coded value 0 … 1
        prsb03-dataelement-13696
        Id prsb03-dataelement-13696 (2020‑09‑09 17:09:21)
        Cardinality 0 … 1
        Description The coded value for advance statement
        Operationalization SNOMED CT: - 816281000000101 | Has advance statement (Mental Capacity Act 2005) (finding) |
        Value Domain
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Free text 0 … 1
        prsb03-dataelement-13697
        Id prsb03-dataelement-13697 (2020‑09‑09 17:10:48)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
        Description Free text field to be used if no code is available
        Operationalization Free text
        Value Domain
        Property
        max length
        150
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Location of document 0 … 1
        prsb03-dataelement-13760
        Id prsb03-dataelement-13760 (2020‑09‑29 14:53:49)
        Cardinality 0 … 1
        Description The location of where the advanced statement is held.
        Relationship
        Operationalization Free text or URL
        Value Domain
        target Used by one transaction, 0 templates, inherited 0 times
         
        folder draft Performing professional 0 … 1
        prsb03-dataelement-12269
        Id prsb03-dataelement-12269 (2019‑05‑31 16:40:44)
        Cardinality 0 … 1
        Description The professional who made the advance statement.
        Relationship
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Name 0 … 1
        prsb03-dataelement-12270
        Id prsb03-dataelement-12270 (2019‑05‑31 16:41:01)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
        Description The name of the professional.
        Rationale Practitioner.name
        Operationalization Free text.
        Value Domain
        Property
        max length
        70
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Role 0 … 1
        prsb03-dataelement-12271
        Id prsb03-dataelement-12271 (2019‑05‑31 16:41:01)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11283 (2019‑05‑30 11:58:48)
        Description The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc
        Rationale Practitioner.PractitionerRole.code
        Operationalization FHIR value set :- SDSjobroletype
        Value Domain
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Grade 0 … 1
        prsb03-dataelement-12272
        Id prsb03-dataelement-12272 (2019‑05‑31 16:41:01)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
        Description The grade of the professional.
        Rationale PractitionerRole.code
        Operationalization Free text
        Value Domain
        Property
        max length
        150
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Speciality 0 … 1
        prsb03-dataelement-12273
        Id prsb03-dataelement-12273 (2019‑05‑31 16:41:01)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11284 (2019‑05‑30 12:01:15)
        Description The specialty of the professional e.g. physiotherapy, oncology, mental health etc
        Rationale PractitionerRole.speciality
        Operationalization NHS data dictionary - Activity treatment function code
        Value Domain
        Property
        max length
        3
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Professional identifier 0 … 1
        prsb03-dataelement-12274
        Id prsb03-dataelement-12274 (2019‑05‑31 16:41:01)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11285 (2019‑05‑30 12:02:46)
        Description Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.
        Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
        Operationalization NHS data dictionary : - Professional registration identifier
        Value Domain
        Property
        max length
        32
        target Used by one transaction, 0 templates, inherited 0 times
         
        folder draft Organisation 0 … 1
        prsb03-dataelement-12275
        Id prsb03-dataelement-12275 (2019‑05‑31 16:41:01)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
        Description The name of the organisation the professional works for.
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Contact details 0 … 1
        prsb03-dataelement-12276
        Id prsb03-dataelement-12276 (2019‑05‑31 16:41:01)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11287 (2019‑05‑30 12:18:13)
        Description Contact details of the professional
        Rationale Practitioner.telecom

        PractitionerRole.telecom

        Organisation.telcom
        Operationalization NHS data dictionary - UK phone number
        Value Domain
        Property
        max length
        35
        target Used by one transaction, 0 templates, inherited 0 times
         
        folder draft Person completing record 0 … 1
        prsb03-dataelement-12277
        Id prsb03-dataelement-12277 (2019‑05‑31 16:41:55)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
        Description Details of the person completing the record.
        Relationship
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Name 0 … 1
        prsb03-dataelement-12278
        Id prsb03-dataelement-12278 (2019‑05‑31 16:42:15)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11290 (2019‑05‑30 12:25:39)
        Description The name of the person completing the record.
        Relationship
        Rationale Composition.author.Practitioner.name
        Operationalization Free text.
        Value Domain
        Property
        max length
        70
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Role 0 … 1
        prsb03-dataelement-12279
        Id prsb03-dataelement-12279 (2019‑05‑31 16:42:15)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
        Description The organisational role of the person completing record.

        Properties

        FHIR PractitionerRole.code of the practitioner completing the record
        Relationship
        Rationale Composition.author.Practitioner.PractitionerRole.code
        Operationalization FHIR value set :- SDSjobrole
        Value Domain
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Grade 0 … 1
        prsb03-dataelement-12280
        Id prsb03-dataelement-12280 (2019‑05‑31 16:42:15)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11292 (2019‑05‑30 12:25:39)
        Description The grade of the person completing the record.
        Relationship
        Rationale PractitionerRole.code
        Operationalization Free text.
        Value Domain
        Property
        max length
        150
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Specialty 0 … 1
        prsb03-dataelement-12281
        Id prsb03-dataelement-12281 (2019‑05‑31 16:42:15)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11293 (2019‑05‑30 12:25:39)
        Description The main specialty of the person completing the record.

        Properties

        FHIR PractitionerRole.specialty
        Relationship
        Rationale PractitionerRole.speciality
        Operationalization NHS data dictionary :- Activity treatment function code
        Value Domain
        Property
        max length
        3
        target Used by one transaction, 0 templates, inherited 0 times
         
        folder draft Organisation 0 … 1
        prsb03-dataelement-12282
        Id prsb03-dataelement-12282 (2019‑05‑31 16:42:15)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
        Description The organisation the person completing the record works for.
        Relationship
        Operationalization NHS data dictionary : - Organisation data service
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Professional identifier 0 … 1
        prsb03-dataelement-12283
        Id prsb03-dataelement-12283 (2019‑05‑31 16:42:15)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11295 (2019‑05‑30 12:25:39)
        Description Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.

        Properties

        FHIR PractitionerRole.Practitioner.identifier (local) Practitioner.identifer (professional)
        Relationship
        Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
        Operationalization NHS data dictionary :- Professional registration identifier
        Value Domain
        Property
        max length
        32
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Date completed 0 … 1
        prsb03-dataelement-12284
        Id prsb03-dataelement-12284 (2019‑05‑31 16:42:15)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11296 (2019‑05‑30 12:25:39)
        Description The date and time the record was completed.
        Relationship
        Rationale Composition.date
        Operationalization Date and time.
        Value Domain
        Property
        Timestamp precision
        at least day, month and year, hour and minute
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Contact details 0 … 1
        prsb03-dataelement-12285
        Id prsb03-dataelement-12285 (2019‑05‑31 16:42:15)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
        Description Contact details of the person completing the record.

        Properties

        FHIR PractitionerRole.telecom
        Relationship
        Rationale Practitioner.telecom

        PractitionerRole.telecom

        Organisation.telcom
        Operationalization NHS data dictionary : - UK telephone number
        Value Domain
        Property
        max length
        35
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Anticipatory medicines/equipment 0 … *
        prsb03-dataelement-10370
        Id prsb03-dataelement-10370 (2018‑10‑31)
        Cardinality 0 … *
        Description 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) |
        Operationalization Free text
        Value Domain
        Property
        max length
        150
        target Used by one transaction, 0 templates, inherited once
         
        folder draft Location 0 … *
        prsb03-dataelement-12079
        Id prsb03-dataelement-12079 (2019‑05‑31 15:39:45)
        Cardinality 0 … *
        Description The location where the contingency plan was prepared.
        Relationship
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Coded value 0 … 1
        prsb03-dataelement-13667
        Id prsb03-dataelement-13667 (2020‑09‑08 22:19:58)
        Cardinality 0 … 1
        Description The coded value for location
        Operationalization NHS data dictionary : - Organisation data service
        Value Domain
        Property
        min length max length
        3 5
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Free text 0 … 1
        prsb03-dataelement-13668
        Id prsb03-dataelement-13668 (2020‑09‑08 22:21:39)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
        Description Free text field to be used if no code is available
        Operationalization Free text
        Value Domain
        Property
        max length
        150
        target Used by one transaction, 0 templates, inherited 0 times
         
        folder draft Performing professional 0 … 1
        prsb03-dataelement-12045
        Id prsb03-dataelement-12045 (2019‑05‑31 15:33:20)
        Cardinality 0 … 1
        Description The professional who prepared the contingency plans.
        Relationship
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Name 0 … 1
        prsb03-dataelement-12046
        Id prsb03-dataelement-12046 (2019‑05‑31 15:33:38)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
        Description The name of the professional.
        Rationale Practitioner.name
        Operationalization Free text.
        Value Domain
        Property
        max length
        70
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Role 0 … 1
        prsb03-dataelement-12047
        Id prsb03-dataelement-12047 (2019‑05‑31 15:33:38)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11283 (2019‑05‑30 11:58:48)
        Description The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc
        Rationale Practitioner.PractitionerRole.code
        Operationalization FHIR value set :- SDSjobroletype
        Value Domain
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Grade 0 … 1
        prsb03-dataelement-12048
        Id prsb03-dataelement-12048 (2019‑05‑31 15:33:38)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
        Description The grade of the professional.
        Rationale PractitionerRole.code
        Operationalization Free text
        Value Domain
        Property
        max length
        150
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Speciality 0 … 1
        prsb03-dataelement-12049
        Id prsb03-dataelement-12049 (2019‑05‑31 15:33:38)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11284 (2019‑05‑30 12:01:15)
        Description The specialty of the professional e.g. physiotherapy, oncology, mental health etc
        Rationale PractitionerRole.speciality
        Operationalization NHS data dictionary - Activity treatment function code
        Value Domain
        Property
        max length
        3
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Professional identifier 0 … 1
        prsb03-dataelement-12050
        Id prsb03-dataelement-12050 (2019‑05‑31 15:33:38)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11285 (2019‑05‑30 12:02:46)
        Description Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.
        Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
        Operationalization NHS data dictionary : - Professional registration identifier
        Value Domain
        Property
        max length
        32
        target Used by one transaction, 0 templates, inherited 0 times
         
        folder draft Organisation 0 … 1
        prsb03-dataelement-12051
        Id prsb03-dataelement-12051 (2019‑05‑31 15:33:38)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
        Description The name of the organisation the professional works for.
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Contact details 0 … 1
        prsb03-dataelement-12052
        Id prsb03-dataelement-12052 (2019‑05‑31 15:33:38)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11287 (2019‑05‑30 12:18:13)
        Description Contact details of the professional
        Rationale Practitioner.telecom

        PractitionerRole.telecom

        Organisation.telcom
        Operationalization NHS data dictionary - UK phone number
        Value Domain
        Property
        max length
        35
        target Used by one transaction, 0 templates, inherited 0 times
         
        folder draft Person completing record 0 … 1
        prsb03-dataelement-12053
        Id prsb03-dataelement-12053 (2019‑05‑31 15:33:49)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
        Description Details of the person completing the record.
        Relationship
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Name 0 … 1
        prsb03-dataelement-12054
        Id prsb03-dataelement-12054 (2019‑05‑31 15:34:15)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11290 (2019‑05‑30 12:25:39)
        Description The name of the person completing the record.
        Relationship
        Rationale Composition.author.Practitioner.name
        Operationalization Free text.
        Value Domain
        Property
        max length
        70
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Role 0 … 1
        prsb03-dataelement-12055
        Id prsb03-dataelement-12055 (2019‑05‑31 15:34:15)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
        Description The organisational role of the person completing record.

        Properties

        FHIR PractitionerRole.code of the practitioner completing the record
        Relationship
        Rationale Composition.author.Practitioner.PractitionerRole.code
        Operationalization FHIR value set :- SDSjobrole
        Value Domain
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Grade 0 … 1
        prsb03-dataelement-12056
        Id prsb03-dataelement-12056 (2019‑05‑31 15:34:15)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11292 (2019‑05‑30 12:25:39)
        Description The grade of the person completing the record.
        Relationship
        Rationale PractitionerRole.code
        Operationalization Free text.
        Value Domain
        Property
        max length
        150
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Specialty 0 … 1
        prsb03-dataelement-12057
        Id prsb03-dataelement-12057 (2019‑05‑31 15:34:15)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11293 (2019‑05‑30 12:25:39)
        Description The main specialty of the person completing the record.

        Properties

        FHIR PractitionerRole.specialty
        Relationship
        Rationale PractitionerRole.speciality
        Operationalization NHS data dictionary :- Activity treatment function code
        Value Domain
        Property
        max length
        3
        target Used by one transaction, 0 templates, inherited 0 times
         
        folder draft Organisation 0 … 1
        prsb03-dataelement-12058
        Id prsb03-dataelement-12058 (2019‑05‑31 15:34:15)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
        Description The organisation the person completing the record works for.
        Relationship
        Operationalization NHS data dictionary : - Organisation data service
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Professional identifier 0 … 1
        prsb03-dataelement-12059
        Id prsb03-dataelement-12059 (2019‑05‑31 15:34:15)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11295 (2019‑05‑30 12:25:39)
        Description Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.

        Properties

        FHIR PractitionerRole.Practitioner.identifier (local) Practitioner.identifer (professional)
        Relationship
        Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
        Operationalization NHS data dictionary :- Professional registration identifier
        Value Domain
        Property
        max length
        32
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Date completed 0 … 1
        prsb03-dataelement-12060
        Id prsb03-dataelement-12060 (2019‑05‑31 15:34:15)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11296 (2019‑05‑30 12:25:39)
        Description The date and time the record was completed.
        Relationship
        Rationale Composition.date
        Operationalization Date and time.
        Value Domain
        Property
        Timestamp precision
        at least day, month and year, hour and minute
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Contact details 0 … 1
        prsb03-dataelement-12061
        Id prsb03-dataelement-12061 (2019‑05‑31 15:34:15)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
        Description Contact details of the person completing the record.

        Properties

        FHIR PractitionerRole.telecom
        Relationship
        Rationale Practitioner.telecom

        PractitionerRole.telecom

        Organisation.telcom
        Operationalization NHS data dictionary : - UK telephone number
        Value Domain
        Property
        max length
        35
        target Used by one transaction, 0 templates, inherited 0 times
         
        folder draft Additional support plans 0 … *
        prsb03-dataelement-502
        Id prsb03-dataelement-502 (2018‑10‑31)
        Cardinality 0 … *
        Context It must be possible to hold additional supporting plans, which may be linked to the care and support plan where the individual or care professional decides that the information should be available to others. Examples of additional supporting plans: asthma plan, mental health plan, tissue viability plan, nutrition plan, falls prevention plan, hospital or other service transfer of care plan, etc.
        Additional supporting plans should be available for others to view, but will only be created, updated and ended by the service creating the plan. These may be made available on the National record Locator Service (NRL) in PDF format.
        Description Additional support plans
        target Used by one transaction, 0 templates, inherited 0 times
         
        folder draft Additional support plan name 0 … 1
        prsb03-dataelement-10402
        Id prsb03-dataelement-10402 (2018‑10‑31)
        Cardinality 0 … 1
        Context Educational and health care plans are produced for people with neurodevelopmental conditions and apply up to the age of 25. However, they transition into adult services earlier so it is important to note that this plan may exist at the same time as a care and support plan.
        Description The name of the particular additional supporting plan, e.g. dieticians plan, wound management plan, discharge management plan and behaviour support plan.
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Coded value 0 … 1
        prsb03-dataelement-14397
        Id prsb03-dataelement-14397 (2021‑07‑06 16:40:30)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-14387 (2021‑07‑06 15:50:58)
        Description The coded value for the type of care plan
        Operationalization SNOMED CT: - 999001471000000108 | Care plan type simple reference set (foundation metadata concept) |
        Value Domain
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Free text 0 … 1
        prsb03-dataelement-14398
        Id prsb03-dataelement-14398 (2021‑07‑06 16:43:20)
        Cardinality 0 … 1
        Description Free text if no coded value is available
        Operationalization Free text
        Value Domain
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Additional support plan content 0 … 1
        prsb03-dataelement-10403
        Id prsb03-dataelement-10403 (2018‑10‑31)
        Cardinality 0 … 1
        Context The format of additional supporting plans will vary according to the type of plan. Some may be structured and coded, some may include diagrams or images.
        Description 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.
        Operationalization Free text
        Value Domain
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Planned review date/interval 0 … 1
        prsb03-dataelement-10405
        Id prsb03-dataelement-10405 (2018‑10‑31)
        Cardinality 0 … 1
        Context When an additional supporting plan is updated a new version of the plan may be linked to the care and support plan, again at the discretion of the individual or care professional.
        Description This is the date/interval when this information will next be reviewed. SNOMED CT tag : - 425268008 | Review of care plan (procedure) |
        Operationalization Date and time
        Value Domain
        target Used by one transaction, 0 templates, inherited 0 times
         
        folder draft Responsibility for review 0 … 1
        prsb03-dataelement-10406
        Id prsb03-dataelement-10406 (2018‑10‑31)
        Cardinality 0 … 1
        Description This is a record of who has responsibility for arranging review of this information. Should include their name, role and contact details.
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Name 0 … 1
        prsb03-dataelement-14348
        Id prsb03-dataelement-14348 (2021‑07‑01 20:44:51)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-10352 (2018‑10‑31)
        Description The name of the professional with responsibility for the care of the person.
        Operationalization Free text
        Value Domain
        Property
        max length
        70
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Role 0 … 1
        prsb03-dataelement-14349
        Id prsb03-dataelement-14349 (2021‑07‑01 20:46:07)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-10353 (2018‑10‑31)
        Description 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) etc
        Operationalization FHIR value set : - SDSjobrole
        Value Domain
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Contact details 0 … 1
        prsb03-dataelement-14350
        Id prsb03-dataelement-14350 (2021‑07‑01 20:49:37)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-10357 (2018‑10‑31)
        Description Contact details of the professional (e.g. telephone number, email address etc.).
        Operationalization Free text
        Value Domain
        Property
        max length
        35
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Date this plan was last updated 0 … 1
        prsb03-dataelement-10407
        Id prsb03-dataelement-10407 (2018‑10‑31)
        Cardinality 0 … 1
        Description This is a record of the date that this information was last updated.
        Operationalization Date and time
        Value Domain
        Property
        Timestamp precision
        at least day, month and year, hour and minute
        target Used by one transaction, 0 templates, inherited 0 times
         
        folder draft Location 0 … 1
        prsb03-dataelement-12080
        Id prsb03-dataelement-12080 (2019‑05‑31 15:40:38)
        Cardinality 0 … 1
        Description The location where the additional support plan was prepared.
        Relationship
        Operationalization ODS code or free text
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Coded value 0 … 1
        prsb03-dataelement-13722
        Id prsb03-dataelement-13722 (2020‑09‑14 13:50:06)
        Cardinality 0 … 1
        Description The coded value for location
        Operationalization NHS data dictionary:- Organisation data service
        Value Domain
        Property
        min length max length
        3 5
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Free text 0 … 1
        prsb03-dataelement-13723
        Id prsb03-dataelement-13723 (2020‑09‑14 13:52:48)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
        Description Free text field to be used if no code is available
        Operationalization Free text
        Value Domain
        Property
        max length
        150
        target Used by one transaction, 0 templates, inherited 0 times
         
        folder draft Performing professional 0 … 1
        prsb03-dataelement-12062
        Id prsb03-dataelement-12062 (2019‑05‑31 15:36:17)
        Cardinality 0 … 1
        Description The professional who prepared the additional support plan.
        Relationship
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Name 0 … 1
        prsb03-dataelement-12063
        Id prsb03-dataelement-12063 (2019‑05‑31 15:36:35)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11282 (2019‑05‑30 11:57:38)
        Description The name of the professional.
        Rationale Practitioner.name
        Operationalization Free text.
        Value Domain
        Property
        max length
        70
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Role 0 … 1
        prsb03-dataelement-12064
        Id prsb03-dataelement-12064 (2019‑05‑31 15:36:35)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11283 (2019‑05‑30 11:58:48)
        Description The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc
        Rationale Practitioner.PractitionerRole.code
        Operationalization FHIR value set :- SDSjobroletype
        Value Domain
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Grade 0 … 1
        prsb03-dataelement-12065
        Id prsb03-dataelement-12065 (2019‑05‑31 15:36:35)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11288 (2019‑05‑30 12:19:40)
        Description The grade of the professional.
        Rationale PractitionerRole.code
        Operationalization Free text
        Value Domain
        Property
        max length
        150
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Speciality 0 … 1
        prsb03-dataelement-12066
        Id prsb03-dataelement-12066 (2019‑05‑31 15:36:35)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11284 (2019‑05‑30 12:01:15)
        Description The specialty of the professional e.g. physiotherapy, oncology, mental health etc
        Rationale PractitionerRole.speciality
        Operationalization NHS data dictionary - Activity treatment function code
        Value Domain
        Property
        max length
        3
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Professional identifier 0 … 1
        prsb03-dataelement-12067
        Id prsb03-dataelement-12067 (2019‑05‑31 15:36:35)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11285 (2019‑05‑30 12:02:46)
        Description Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.
        Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
        Operationalization NHS data dictionary : - Professional registration identifier
        Value Domain
        Property
        max length
        32
        target Used by one transaction, 0 templates, inherited 0 times
         
        folder draft Organisation 0 … 1
        prsb03-dataelement-12068
        Id prsb03-dataelement-12068 (2019‑05‑31 15:36:35)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11286 (2019‑05‑30 12:17:19)
        Description The name of the organisation the professional works for.
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Contact details 0 … 1
        prsb03-dataelement-12069
        Id prsb03-dataelement-12069 (2019‑05‑31 15:36:35)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11287 (2019‑05‑30 12:18:13)
        Description Contact details of the professional
        Rationale Practitioner.telecom

        PractitionerRole.telecom

        Organisation.telcom
        Operationalization NHS data dictionary - UK phone number
        Value Domain
        Property
        max length
        35
        target Used by one transaction, 0 templates, inherited 0 times
         
        folder draft Person completing record 0 … 1
        prsb03-dataelement-12070
        Id prsb03-dataelement-12070 (2019‑05‑31 15:36:49)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11289 (2019‑05‑30 12:24:39)
        Description Details of the person completing the record.
        Relationship
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Name 0 … 1
        prsb03-dataelement-12071
        Id prsb03-dataelement-12071 (2019‑05‑31 15:37:13)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11290 (2019‑05‑30 12:25:39)
        Description The name of the person completing the record.
        Relationship
        Rationale Composition.author.Practitioner.name
        Operationalization Free text.
        Value Domain
        Property
        max length
        70
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Role 0 … 1
        prsb03-dataelement-12072
        Id prsb03-dataelement-12072 (2019‑05‑31 15:37:13)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11291 (2019‑05‑30 12:25:39)
        Description The organisational role of the person completing record.

        Properties

        FHIR PractitionerRole.code of the practitioner completing the record
        Relationship
        Rationale Composition.author.Practitioner.PractitionerRole.code
        Operationalization FHIR value set :- SDSjobrole
        Value Domain
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Grade 0 … 1
        prsb03-dataelement-12073
        Id prsb03-dataelement-12073 (2019‑05‑31 15:37:13)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11292 (2019‑05‑30 12:25:39)
        Description The grade of the person completing the record.
        Relationship
        Rationale PractitionerRole.code
        Operationalization Free text.
        Value Domain
        Property
        max length
        150
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Specialty 0 … 1
        prsb03-dataelement-12074
        Id prsb03-dataelement-12074 (2019‑05‑31 15:37:13)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11293 (2019‑05‑30 12:25:39)
        Description The main specialty of the person completing the record.

        Properties

        FHIR PractitionerRole.specialty
        Relationship
        Rationale PractitionerRole.speciality
        Operationalization NHS data dictionary :- Activity treatment function code
        Value Domain
        Property
        max length
        3
        target Used by one transaction, 0 templates, inherited 0 times
         
        folder draft Organisation 0 … 1
        prsb03-dataelement-12075
        Id prsb03-dataelement-12075 (2019‑05‑31 15:37:13)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11294 (2019‑05‑30 12:25:39)
        Description The organisation the person completing the record works for.
        Relationship
        Operationalization NHS data dictionary : - Organisation data service
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Professional identifier 0 … 1
        prsb03-dataelement-12076
        Id prsb03-dataelement-12076 (2019‑05‑31 15:37:13)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11295 (2019‑05‑30 12:25:39)
        Description Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.

        Properties

        FHIR PractitionerRole.Practitioner.identifier (local) Practitioner.identifer (professional)
        Relationship
        Rationale Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier (for local role identifiers)
        Operationalization NHS data dictionary :- Professional registration identifier
        Value Domain
        Property
        max length
        32
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Date completed 0 … 1
        prsb03-dataelement-12077
        Id prsb03-dataelement-12077 (2019‑05‑31 15:37:13)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11296 (2019‑05‑30 12:25:39)
        Description The date and time the record was completed.
        Relationship
        Rationale Composition.date
        Operationalization Date and time.
        Value Domain
        Property
        Timestamp precision
        at least day, month and year, hour and minute
        target Used by one transaction, 0 templates, inherited 0 times
         
        draft Contact details 0 … 1
        prsb03-dataelement-12078
        Id prsb03-dataelement-12078 (2019‑05‑31 15:37:13)
        Cardinality 0 … 1
        Concept inherits from draft prsb03-dataelement-11297 (2019‑05‑30 12:25:39)
        Description Contact details of the person completing the record.

        Properties

        FHIR PractitionerRole.telecom
        Relationship
        Rationale Practitioner.telecom

        PractitionerRole.telecom

        Organisation.telcom
        Operationalization NHS data dictionary : - UK telephone number
        Value Domain
        Property
        max length
        35
        target Used by one transaction, 0 templates, inherited 0 times