Scenario Emergency care discharge 2.16.840.1.113883.3.1937.777.28.3.3

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Name	Details [‑]
Emergency care discharge prsb03-scenario-3
	Version / effective date 3.2 - 2018‑10‑31
	Description	Emergency Care discharge v3.2 - Minor updates to cardinalities for alignment with other Transfers of care standards - Updates to valuesets to match current ECDS codes - Addition of 'Referred by (emegrency care)' element to Referral Details Emergency Care discharge v3.1  - Updates to align MROs to original standard Emergency care discharge 3.0  - Updates as part of maintenance release 2 Emergency care discharge 2.1 Updated meds
Emergency care discharge prsb03-transaction-12link
	Version / effective date 3.2 - 2018‑10‑31
	Description	Emergency care discharge
Emergency care discharge prsb03-transaction-102link
	Version / effective date 3.2 - 2018‑10‑31     Label sc-3
	Description	Emergency care discharge
	Actor	Sender (organization) General practitioner
	Associations	Data Set (for transaction) 1(2.16.840.1.113883.3.1937.777.28.1.1 / DYNAMIC)
	Contained concepts
	Concept Card/Conf Id Person demographics 1 … 1 Mandatory prsb03-dataelement-10868link The person's details and contact information. Person name 1 … 1 Mandatory prsb03-dataelement-10869link Details of the person's name   Person first name 1 … * Mandatory prsb03-dataelement-13799link The first name(s) of the person. This includes middle names.NHS data dictionary :- Person given name   Person family name 1 … * Mandatory prsb03-dataelement-13800link The family name or surname of the personNHS data dictionary : - Person family name   Person preferred name 0 … 1 prsb03-dataelement-10870link The name by which a person wishes to be addressed. The preferred name volunteered by the person or a preferred name given by PDS that the person has asked to be called by.NHS data dictionary: - Person full name   Title 0 … 1 prsb03-dataelement-13089link Person's titleNHS data dictionary: - Person title   Person name suffix 0 … * prsb03-dataelement-13798link A textual suffix that may be added to the end of a PERSON's name, for example, OBE, MBE, BSc, JP, GMNHS data dictionary: - Person suffix   Person full name 0 … 1 prsb03-dataelement-13801link The full name of the person in text representation.NHS data dictionary :- Person full name   Date of birth 1 … 1 Mandatory prsb03-dataelement-10871link The date of birth of the person.NHS data dictionary:- Person birth date   Gender 0 … 1 prsb03-dataelement-10872link The person's stated gender.NHS data dictionary :- Person stated gender code   Ethnicity 0 … 1 prsb03-dataelement-10874link The ethnicity of the person as specified by the person.NHS data dictionary :- Ethnic category   Religion 0 … 1 prsb03-dataelement-10876link The religious affiliation as specified by the person. SNOMED_CT:- Religion   Sex 0 … 1 prsb03-dataelement-10877link The person’s phenotypic sex. Determines how the person will be treated clinically.NHS data dictionary: - person phenotypic sex   NHS number 0 … 1 prsb03-dataelement-10879link The unique identifier for a person within the NHS in England and Wales.NHS data dictionary:- NHS number   NHS number status indicator 0 … 1 prsb03-dataelement-13297link Provides an indication of the reliability of an NHS Number.NHS data dictionary :- NHS number status indicator   Other identifier 0 … * prsb03-dataelement-10880link Country specific or local identifier, e.g. Community Health Index (CHI) in Scotland. NHS data dictionary: - Local patient identifier(extended), Health and care number (NI only), Community health index number (Scotland only) Person's address 1 … * Mandatory prsb03-dataelement-10881link Person’s usual place of residence, and where relevant temporary and correspondence addresses.   Address line 1 1 … 1 Mandatory prsb03-dataelement-13082link Person's first line of address. NHS data dictionary :-  Address line 1   Address line 2 0 … 1 prsb03-dataelement-13083link Person's second line of address. NHS data dictionary :- Address line 2   Address line 3 0 … 1 prsb03-dataelement-13084link Person's third line of address. NHS data dictionary : - Address line 3   Address line 4 0 … 1 prsb03-dataelement-13085link Person's fourth line of address. NHS data dictionary : - Address line 4   Address line 5 0 … 1 prsb03-dataelement-13086link Person's fifth line of address.NHS data dictionary : - Address line 5   Postcode 0 … 1 prsb03-dataelement-13087link The person's postcode.NHS data dictionary :- Postcode of usual address   Address type 0 … 1 prsb03-dataelement-13221link The type of address e.g. Main address, Temp addressNHS data dictionary : - Address association type Person's contact details 0 … 1 prsb03-dataelement-13804link Details of the person's contact information.   Preferred contact method 0 … 1 prsb03-dataelement-10886link Preferred contact method, e.g. email, letter, phone, text message etc.NHS data dictionary :- Communication contact method Person's telephone number details 0 … * prsb03-dataelement-10883link The person's telephone number details   Person's telephone number 0 … 1 prsb03-dataelement-13808link The person's telephone numberNHS data dictionary : - UK telephone number   Person's telephone number type 0 … 1 prsb03-dataelement-13805link The contact type e.g. home, mobileFHIR value set: - Contact point use   Preference of telephone number 0 … 1 prsb03-dataelement-13809link The preferred order of use for the telephone numberPreference of use 1-5, 1 being the highest. Person's email address details 0 … * prsb03-dataelement-13807link Details of the person's email address   Person's email address 0 … 1 prsb03-dataelement-10882link Email address of the person.NHS data dictionary :- Contact email address   Person's email address type 0 … 1 prsb03-dataelement-13811link The type of email address, home, workFHIR value set: - Contact point use   Preference of email address 0 … 1 prsb03-dataelement-13810link The preferred order of use of email addressPreference of use 1-5, 1 being the highest.   Other contact information 0 … 1 prsb03-dataelement-13806link Contact details via fax, sms, urlNHS data dictionary:- Communication contact string   Organ and tissue donation 0 … 1 prsb03-dataelement-13847link Whether the person has opted out of automatic organ and/or tissue donation where applicable. This is information provided by the national register.Flag: - Yes or No   Educational establishment 0 … 1 prsb03-dataelement-10911link If the person is a child, name and address of where the child attends, eg play group, nursery, school.Free text or ODS code where available. GP practice 1 … 1 Mandatory prsb03-dataelement-101link Details of the person's GP practice. GP practice record entry 0 … * prsb03-dataelement-10643link This is an GP practice record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items   GP name 0 … 1 prsb03-dataelement-10003link The name of the person's GP. If the person is registered with a GP practice, their usual GP name will be something volunteered by the person or their representative.Free text   GP practice details 0 … 1 prsb03-dataelement-10002link Name and address of the person's registered GP practice Registered GP practice details are available from the Person Demographics Service (PDS), or volunteered from the person or their representative. Include details of the practice name and address.Free text   GP practice identifier 1 … 1 Mandatory prsb03-dataelement-10001link The identifier of the registered GP practice. NHS data dictionary : - General medical practice code (patient registration) Safeguarding 0 … 1 prsb03-dataelement-271link The safeguarding details of the person. Safeguarding concerns 0 … * prsb03-dataelement-10821link Details of safeguarding concerns   Safeguarding indicator 0 … 1 prsb03-dataelement-13428link Indicates whether or not the hospital considers that there are safeguarding issues associated with the patient.Flag: No =N: Yes = Y   Safeguarding concerns date 0 … 1 prsb03-dataelement-10172link The date the safeguarding concerns were identified.Date and time   Safeguarding concerns end date 0 … 1 prsb03-dataelement-10766link The date safeguarding concerns ended.Date and time Location 0 … 1 prsb03-dataelement-10173link The location where the safeguarding concerns were identified.   Coded value 0 … 1 prsb03-dataelement-13437link The coded value of locationNHS data dictionary : - Organisation code   Free text 0 … 1 prsb03-dataelement-13438link Free text field to be used if no code is availableFree text Safeguarding concerns 0 … * prsb03-dataelement-10171link Identified safeguarding concerns.   Coded value 0 … 1 prsb03-dataelement-13756link The coded value for safeguarding concernsSNOMED CT : - ^999002381000000108 | Safeguarding issues simple reference set (foundation metadata concept) |   Free text 0 … 1 prsb03-dataelement-13757link Free text field to be used if no code is availableFree text Performing professional 0 … 1 prsb03-dataelement-11358link The professional who identified the safeguarding concerns.   Name 0 … 1 prsb03-dataelement-11359link The name of the professional.Free text.   Role 0 … 1 prsb03-dataelement-11360link The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype   Grade 0 … 1 prsb03-dataelement-11361link The grade of the professional.Free text   Speciality 0 … 1 prsb03-dataelement-11362link The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code   Professional identifier 0 … 1 prsb03-dataelement-11363link Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier Organisation 0 … 1 prsb03-dataelement-11364link The name of the organisation the professional works for.   Contact details 0 … 1 prsb03-dataelement-11365link Contact details of the professionalNHS data dictionary - UK phone number Person completing record 0 … 1 prsb03-dataelement-11366link Details of the person completing the record.   Name 0 … 1 prsb03-dataelement-11367link The name of the person completing the record.Free text.   Role 0 … 1 prsb03-dataelement-11368link The organisational role of the person completing record.FHIR value set :- SDSjobrole   Grade 0 … 1 prsb03-dataelement-11369link The grade of the person completing the record.Free text.   Specialty 0 … 1 prsb03-dataelement-11370link The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code Organisation 0 … 1 prsb03-dataelement-11371link The organisation the person completing the record works for. NHS data dictionary : - Organisation data service   Professional identifier 0 … 1 prsb03-dataelement-11372link Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier   Date completed 0 … 1 prsb03-dataelement-11373link The date and time the record was completed.Date and time.   Contact details 0 … 1 prsb03-dataelement-11374link Contact details of the person completing the record. NHS data dictionary : - UK telephone number   Comment 0 … 1 prsb03-dataelement-10175link Further details on safeguarding concerns.Free text Referral details 0 … 1 prsb03-dataelement-105link The details of the referral. Referral details record entry 0 … * prsb03-dataelement-10917link This is the referral details record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.   Date 0 … 1 prsb03-dataelement-10006link The date of referralDate and time Referrer details 1 … 1 Mandatory prsb03-dataelement-10005link The details of the referrer that is making the referral or the transfer. This could be the person, GP surgery, department, specialty, sub-specialty, educational institution, mental health team, care home etc.   Name 1 … 1 Mandatory prsb03-dataelement-10971link The name of the referrer.Free text   Role 0 … 1 prsb03-dataelement-10972link Role of the referrer.FHIR value set : - sdsjobrole   Grade 0 … 1 prsb03-dataelement-10973link The grade of the referrer.Free text   Team 0 … 1 prsb03-dataelement-12409link The team or department of the referrer.Free text   Specialty 0 … 1 prsb03-dataelement-12410link The specialty of the referrer.NHS data dictionary - Activity treatment function code Service 0 … 1 prsb03-dataelement-12411link The service of the referrer.   Coded value 0 … 1 prsb03-dataelement-13397link The coded value for serviceSNOMED CT: - 1127531000000102 |Services simple reference set (foundation metadata concept)|   Free text 0 … 1 prsb03-dataelement-13398link Free text field to be used if no code is availableFree text Organisation 0 … 1 prsb03-dataelement-10974link The organisation of the referrer.   Coded value 0 … 1 prsb03-dataelement-13399link The coded value for organisation codeNHS data dictionary : - Organisation data service   Free text 0 … 1 prsb03-dataelement-13400link Free text field to be used if no code is availableFree text   Referred by (emergency care) 0 … 1 prsb03-dataelement-15207link The details of where the person was referred to emergency care from. SNOMED CT: - 999002991000000109 | Emergency care attendance source simple reference set (foundation metadata concept) |   Contact details 0 … 1 prsb03-dataelement-10975link The contact details of the referrer.Free text Contacts with professionals 1 … 1 Mandatory prsb03-dataelement-169link The details of the person’s contact with a professional. Contacts with professionals record entry 1 … * Mandatory prsb03-dataelement-10718link This is a contacts record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.   Date and time of contact 1 … 1 Mandatory prsb03-dataelement-10069link Date and time of the contact.Date and time. Discharge details 1 … 1 prsb03-dataelement-191link Discharge details Discharge details record entry 0 … * prsb03-dataelement-10919link This is the discharge details record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.   Date of discharge 1 … 1 Mandatory prsb03-dataelement-10096link The date and time of dischargeDate and time   Discharge destination 1 … 1 Mandatory prsb03-dataelement-10091link The destination of the person on discharge. SNOMED: - 999003011000000105 | Emergency care discharge destination simple reference set (foundation metadata concept) |   Discharge status 1 … 1 Mandatory prsb03-dataelement-10092link Patient status on discharge from emergency care SNOMED CT: - 999003021000000104 | Emergency care discharge status simple reference set (foundation metadata concept) | Presenting complaints or issues 1 … 1 Mandatory prsb03-dataelement-210link Presenting complaints or issues Presenting complaint or issue 1 … 1 Mandatory prsb03-dataelement-13784link The health problem or issue experienced by the person resulting in their attendance. This may include disease state, medical condition, response and reactions to therapies. e.g., blackout, dizziness, chest pain, follow up from admission, falls, a specific procedure, investigation or treatment.   Coded value 0 … 1 prsb03-dataelement-13785link The coded value for presenting complaint or issueSNOMED CT : - ^1127581000000103 |Health issues simple reference set|   Free text 0 … 1 prsb03-dataelement-13786link Free text Problem list 1 … 1 Mandatory prsb03-dataelement-10927link A summary of the problems that require investigation or treatment. Problem list record entry 0 … * prsb03-dataelement-10928link This is a problem list record entry. There may be 0 to many record entries under problem list. Each record entry is made up of a number of elements or data items.   Date 0 … 1 prsb03-dataelement-10929link The date the problem was identified.Date and time Performing professional 0 … 1 prsb03-dataelement-12133link The professional who identified the problem.   Name 0 … 1 prsb03-dataelement-12134link The name of the professional.Free text.   Role 0 … 1 prsb03-dataelement-12135link The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype   Grade 0 … 1 prsb03-dataelement-12136link The grade of the professional.Free text   Speciality 0 … 1 prsb03-dataelement-12137link The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code   Professional identifier 0 … 1 prsb03-dataelement-12138link Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier Organisation 0 … 1 prsb03-dataelement-12139link The name of the organisation the professional works for.   Contact details 0 … 1 prsb03-dataelement-12140link Contact details of the professionalNHS data dictionary - UK phone number Location 0 … 1 prsb03-dataelement-10931link The location the problem was identified.   Coded value 0 … 1 prsb03-dataelement-13242link The coded value for location.NHS data dictionary : - Organisation data service code   Free text 0 … 1 prsb03-dataelement-13243link Free text field to be used if no code is availableFree text Problem 1 … 1 Mandatory prsb03-dataelement-10932link A condition which needs addressing and so is important for every professional to know about when seeing the person. Problems may include diagnoses, symptoms, disabilities and social or behavioural issues   Coded value 0 … 1 prsb03-dataelement-13244link The coded value for the problem list.SNOMED CT : - ^1127581000000103 |Health issues simple reference set|   Free text 0 … 1 prsb03-dataelement-13245link Free text field to be used if no code is availableFree text   Onset date 0 … 1 prsb03-dataelement-10933link A date or estimated date that the problem beganDate and time   End Date 0 … 1 prsb03-dataelement-10934link The date or estimated date the problem was resolved.Date and time. Problem on discharge 1 … 1 prsb03-dataelement-14262link The main problem or diagnosis on discharge. Problems may include diagnoses, symptoms, disabilities and social or behavioural issues, and comprise the ‘Problem list’   Coded value 0 … 1 prsb03-dataelement-14263link The coded value for the problem list.SNOMED CT : - ^1127581000000103 |Health issues simple reference set|   Free text 0 … 1 prsb03-dataelement-14264link Free text field to be used if no code is availableFree text   Stage of disease 0 … 1 prsb03-dataelement-10935link The stage of the disease where relevant.Free text Person completing record 0 … 1 prsb03-dataelement-12141link Details of the person completing the record.   Name 0 … 1 prsb03-dataelement-12142link The name of the person completing the record.Free text.   Role 0 … 1 prsb03-dataelement-12143link The organisational role of the person completing record.FHIR value set :- SDSjobrole   Grade 0 … 1 prsb03-dataelement-12144link The grade of the person completing the record.Free text.   Specialty 0 … 1 prsb03-dataelement-12145link The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code Organisation 0 … 1 prsb03-dataelement-12146link The organisation the person completing the record works for. NHS data dictionary : - Organisation data service   Professional identifier 0 … 1 prsb03-dataelement-12147link Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier   Date completed 0 … 1 prsb03-dataelement-12148link The date and time the record was completed.Date and time.   Contact details 0 … 1 prsb03-dataelement-12149link Contact details of the person completing the record. NHS data dictionary : - UK telephone number   Comment 0 … * prsb03-dataelement-10936link Supporting text may be given covering the problem.Free text Procedures and therapies 0 … 1 prsb03-dataelement-238link The details of any procedures performed. Includes both psychological and medical therapies and procedures (e.g. cognitive behaviour therapy, hip replacement) Procedure record entry 0 … * prsb03-dataelement-10652link This is a procedure record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.   Date 0 … 1 prsb03-dataelement-10138link The date the procedure was performed.Date and time. Location 0 … 1 prsb03-dataelement-13246link The location where the procedure was undertaken.   Coded value 0 … 1 prsb03-dataelement-13247link The coded value for location.NHS data dictionary : - Organisation data service code   Free text 0 … 1 prsb03-dataelement-13248link Free text field to be used if no code is availableFree text Performing professional 0 … 1 prsb03-dataelement-12150link The professional who performed the procedure.   Name 0 … 1 prsb03-dataelement-12151link The name of the professional.Free text.   Role 0 … 1 prsb03-dataelement-12152link The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype   Grade 0 … 1 prsb03-dataelement-12153link The grade of the professional.Free text   Speciality 0 … 1 prsb03-dataelement-12154link The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code   Professional identifier 0 … 1 prsb03-dataelement-12155link Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier Organisation 0 … 1 prsb03-dataelement-12156link The name of the organisation the professional works for.   Contact details 0 … 1 prsb03-dataelement-12157link Contact details of the professionalNHS data dictionary - UK phone number Procedure 1 … 1 Mandatory prsb03-dataelement-10141link The therapeutic or diagnostic procedure performed. Includes both psychological and medical therapies and procedures (e.g. cognitive behaviour therapy, or follow-up interventions as a result of physical health checks). Complementary or alternative procedures and therapies should be recorded here.   Coded value 0 … 1 prsb03-dataelement-13249link The procedure code.SNOMED CT : - <<71388002 |Procedure| OR <<129125009 |Procedure with explicit context|   Free text 0 … 1 prsb03-dataelement-13250link Free text field to be used if no code is availableFree text Anatomical site 0 … 1 prsb03-dataelement-10142link The body site of the procedure   Coded value 0 … 1 prsb03-dataelement-13251link The coded value of the anatomical site.SNOMED CT :- <123037004 |Body structure (body structure)|   Free text 0 … 1 prsb03-dataelement-13252link Free text field to be used if no code is availableFree text Laterality 0 … 1 prsb03-dataelement-10143link Laterality of the procedure   Coded value 0 … 1 prsb03-dataelement-13253link The coded value for laterality.SNOMED CT:- <182353008 |Side (qualifier value)|   Free text 0 … 1 prsb03-dataelement-13254link Free text field to be used if no code is availableFree text Complications related to procedure 0 … 1 prsb03-dataelement-10144link Details of any intra-operative complications encountered during the procedure, arising during the person’s stay in the recovery unit or directly attributable to the procedure.   Coded value 0 … 1 prsb03-dataelement-13255link The coded value for complications relating to procedure.SNOMED CT : - <404684003 |Clinical finding (finding)|   Free text 0 … 1 prsb03-dataelement-13256link Free text field to be used if no code is availableFree text Specific anesthesia issues 0 … 1 prsb03-dataelement-10145link Details of any adverse reaction to any anesthetic agents including local anesthesia. Problematic intubation, transfusion reaction, etc.   Coded value 0 … 1 prsb03-dataelement-13257link The coded value for specific anesthesia issues.SNOMED CT   Free text 0 … 1 prsb03-dataelement-13258link Free text field to be used if no code is availableFree text Person completing record 0 … 1 prsb03-dataelement-12158link Details of the person completing the record.   Name 0 … 1 prsb03-dataelement-12159link The name of the person completing the record.Free text.   Role 0 … 1 prsb03-dataelement-12160link The organisational role of the person completing record.FHIR value set :- SDSjobrole   Grade 0 … 1 prsb03-dataelement-12161link The grade of the person completing the record.Free text.   Specialty 0 … 1 prsb03-dataelement-12162link The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code Organisation 0 … 1 prsb03-dataelement-12163link The organisation the person completing the record works for. NHS data dictionary : - Organisation data service   Professional identifier 0 … 1 prsb03-dataelement-12164link Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier   Date completed 0 … 1 prsb03-dataelement-12165link The date and time the record was completed.Date and time.   Contact details 0 … 1 prsb03-dataelement-12166link Contact details of the person completing the record. NHS data dictionary : - UK telephone number   Comment 0 … 1 prsb03-dataelement-10146link Any further textual comment to clarify such as statement that information is partial or incomplete. Also indicate the outcome of the procedure.Free text Clinical Summary 1 … 1 Mandatory prsb03-dataelement-247link Clinical Summary   Clinical summary 1 … 1 Mandatory prsb03-dataelement-10147link Summary of the encounter. Where possible, very brief. This may include interpretation of findings and results; differential diagnoses, opinion and specific action(s). Planned actions will be recorded under ‘plan’.Free text Risks 0 … 1 prsb03-dataelement-276link Details of any risks related to the person. Risks to self 0 … * prsb03-dataelement-10176link Details of the persons risk to self   Start date of risk 0 … 1 prsb03-dataelement-11893link The start date of the risk.Date and time   End date of risk 0 … 1 prsb03-dataelement-11894link The date the risk ended.Date and time   Risk to self 0 … 1 prsb03-dataelement-13579link Risks the person poses to themselves, e.g. suicide, overdose, self-harm, self-neglect.SNOMED CT: - <281694009 |Finding of at risk (finding)| Location 0 … 1 prsb03-dataelement-11895link The location where the risk was identified.   Coded value 0 … 1 prsb03-dataelement-13586link The coded value for locationNHS data dictionary : - Organisation service code   Free text 0 … 1 prsb03-dataelement-13587link Free text field to be used if no code is availableFree text Performing professional 0 … 1 prsb03-dataelement-11896link The professional who identified the risk.   Name 0 … 1 prsb03-dataelement-11897link The name of the professional.Free text.   Role 0 … 1 prsb03-dataelement-11898link The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype   Grade 0 … 1 prsb03-dataelement-11899link The grade of the professional.Free text   Speciality 0 … 1 prsb03-dataelement-11900link The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code   Professional identifier 0 … 1 prsb03-dataelement-11901link Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier Organisation 0 … 1 prsb03-dataelement-11902link The name of the organisation the professional works for.   Contact details 0 … 1 prsb03-dataelement-11903link Contact details of the professionalNHS data dictionary - UK phone number Person completing record 0 … 1 prsb03-dataelement-11904link Details of the person completing the record.   Name 0 … 1 prsb03-dataelement-11905link The name of the person completing the record.Free text.   Role 0 … 1 prsb03-dataelement-11906link The organisational role of the person completing record.FHIR value set :- SDSjobrole   Grade 0 … 1 prsb03-dataelement-11907link The grade of the person completing the record.Free text.   Specialty 0 … 1 prsb03-dataelement-11908link The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code Organisation 0 … 1 prsb03-dataelement-11909link The organisation the person completing the record works for. NHS data dictionary : - Organisation data service   Professional identifier 0 … 1 prsb03-dataelement-11910link Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier   Date completed 0 … 1 prsb03-dataelement-11911link The date and time the record was completed.Date and time.   Contact details 0 … 1 prsb03-dataelement-11912link Contact details of the person completing the record. NHS data dictionary : - UK telephone number Risks to others 0 … * prsb03-dataelement-10177link Details of the person's risk to others   Start date of risk 0 … 1 prsb03-dataelement-11913link The start date of the risk.Date and time   End date of risk 0 … 1 prsb03-dataelement-11914link The date the risk ended.Date and time   Risks to others 0 … 1 prsb03-dataelement-13580link Risks to professionals or others.SNOMED CT: - <<391155006 |At risk of harming others (finding)| Location 0 … 1 prsb03-dataelement-11915link The location where the risk to others was identified.   Coded value 0 … 1 prsb03-dataelement-13588link The coded value for locationNHS data dictionary : - Organisation data service   Free text 0 … 1 prsb03-dataelement-13589link Free text field to be used if no code is availableFree text Performing professional 0 … 1 prsb03-dataelement-11916link The professional who identifies the risk to others.   Name 0 … 1 prsb03-dataelement-11917link The name of the professional.Free text.   Role 0 … 1 prsb03-dataelement-11918link The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype   Grade 0 … 1 prsb03-dataelement-11919link The grade of the professional.Free text   Speciality 0 … 1 prsb03-dataelement-11920link The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code   Professional identifier 0 … 1 prsb03-dataelement-11921link Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier Organisation 0 … 1 prsb03-dataelement-11922link The name of the organisation the professional works for.   Contact details 0 … 1 prsb03-dataelement-11923link Contact details of the professionalNHS data dictionary - UK phone number Person completing record 0 … 1 prsb03-dataelement-11924link Details of the person completing the record.   Name 0 … 1 prsb03-dataelement-11925link The name of the person completing the record.Free text.   Role 0 … 1 prsb03-dataelement-11926link The organisational role of the person completing record.FHIR value set :- SDSjobrole   Grade 0 … 1 prsb03-dataelement-11927link The grade of the person completing the record.Free text.   Specialty 0 … 1 prsb03-dataelement-11928link The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code Organisation 0 … 1 prsb03-dataelement-11929link The organisation the person completing the record works for. NHS data dictionary : - Organisation data service   Professional identifier 0 … 1 prsb03-dataelement-11930link Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier   Date completed 0 … 1 prsb03-dataelement-11931link The date and time the record was completed.Date and time.   Contact details 0 … 1 prsb03-dataelement-11932link Contact details of the person completing the record. NHS data dictionary : - UK telephone number Risk from others 0 … * prsb03-dataelement-10178link Risks to the person from an identified individual e.g. family member etc.Free Text.   Start date of risk 0 … 1 prsb03-dataelement-11933link The start date of the risk.Date and time   End date of risk 0 … 1 prsb03-dataelement-11934link The date the risk ended.Date and time   Risk from others 0 … 1 prsb03-dataelement-13581link Risks to the person from an identified individual e.g. family member etc.SNOMED CT: - <281694009 |Finding of at risk (finding)| Location 0 … 1 prsb03-dataelement-11935link The location where the risk from others was identified.   Coded value 0 … 1 prsb03-dataelement-13590link The coded value for locationNHS data dictionary : - Organisation data service   Free text 0 … 1 prsb03-dataelement-13591link Free text field to be used if no code is availableFree text Performing professional 0 … 1 prsb03-dataelement-11936link The professional who identified the risk from others.   Name 0 … 1 prsb03-dataelement-11937link The name of the professional.Free text.   Role 0 … 1 prsb03-dataelement-11938link The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype   Grade 0 … 1 prsb03-dataelement-11939link The grade of the professional.Free text   Speciality 0 … 1 prsb03-dataelement-11940link The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code   Professional identifier 0 … 1 prsb03-dataelement-11941link Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier Organisation 0 … 1 prsb03-dataelement-11942link The name of the organisation the professional works for.   Contact details 0 … 1 prsb03-dataelement-11943link Contact details of the professionalNHS data dictionary - UK phone number Person completing record 0 … 1 prsb03-dataelement-11944link Details of the person completing the record.   Name 0 … 1 prsb03-dataelement-11945link The name of the person completing the record.Free text.   Role 0 … 1 prsb03-dataelement-11946link The organisational role of the person completing record.FHIR value set :- SDSjobrole   Grade 0 … 1 prsb03-dataelement-11947link The grade of the person completing the record.Free text.   Specialty 0 … 1 prsb03-dataelement-11948link The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code Organisation 0 … 1 prsb03-dataelement-11949link The organisation the person completing the record works for. NHS data dictionary : - Organisation data service   Professional identifier 0 … 1 prsb03-dataelement-11950link Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier   Date completed 0 … 1 prsb03-dataelement-11951link The date and time the record was completed.Date and time.   Contact details 0 … 1 prsb03-dataelement-11952link Contact details of the person completing the record. NHS data dictionary : - UK telephone number Risk of accidents 0 … * prsb03-dataelement-10751link Details of the risks the person poses to themselves from accidents.   Start date of risk 0 … 1 prsb03-dataelement-11953link The start date of the risk.Date and time   End date of risk 0 … 1 prsb03-dataelement-11954link The date the risk ended.Date and time   Risk of accidents 0 … 1 prsb03-dataelement-13582link Risks the person poses to themselves from accidents.Free text Location 0 … 1 prsb03-dataelement-11955link The location where the risk of accidents was identified.   Coded value 0 … 1 prsb03-dataelement-13592link The coded value for locationNHS data dictionary : - Organisation data service   Free text 0 … 1 prsb03-dataelement-13593link Free text field to be used if no coded text available Performing professional 0 … 1 prsb03-dataelement-11956link The professional who identified the risk of accidents.   Name 0 … 1 prsb03-dataelement-11957link The name of the professional.Free text.   Role 0 … 1 prsb03-dataelement-11958link The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype   Grade 0 … 1 prsb03-dataelement-11959link The grade of the professional.Free text   Speciality 0 … 1 prsb03-dataelement-11960link The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code   Professional identifier 0 … 1 prsb03-dataelement-11961link Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier Organisation 0 … 1 prsb03-dataelement-11962link The name of the organisation the professional works for.   Contact details 0 … 1 prsb03-dataelement-11963link Contact details of the professionalNHS data dictionary - UK phone number Person completing record 0 … 1 prsb03-dataelement-11964link Details of the person completing the record.   Name 0 … 1 prsb03-dataelement-11965link The name of the person completing the record.Free text.   Role 0 … 1 prsb03-dataelement-11966link The organisational role of the person completing record.FHIR value set :- SDSjobrole   Grade 0 … 1 prsb03-dataelement-11967link The grade of the person completing the record.Free text.   Specialty 0 … 1 prsb03-dataelement-11968link The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code Organisation 0 … 1 prsb03-dataelement-11969link The organisation the person completing the record works for. NHS data dictionary : - Organisation data service   Professional identifier 0 … 1 prsb03-dataelement-11970link Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier   Date completed 0 … 1 prsb03-dataelement-11971link The date and time the record was completed.Date and time.   Contact details 0 … 1 prsb03-dataelement-11972link Contact details of the person completing the record. NHS data dictionary : - UK telephone number Other risks 0 … * prsb03-dataelement-10802link Details of other risks, factors or behaviours relating to the person.   Start date of risk 0 … 1 prsb03-dataelement-11973link The start date of the risk.Date and time   End date of risk 0 … 1 prsb03-dataelement-11974link The date the risk ended.Date and time   Other risks 0 … 1 prsb03-dataelement-13583link Other risks, factors or behaviours relating to the person.Free text Location 0 … 1 prsb03-dataelement-11975link The location where the other risks were identified.   Coded value 0 … 1 prsb03-dataelement-13594link The coded value for locationNHS data dictionary : - Organisation data service   Free text 0 … 1 prsb03-dataelement-13595link Free text field to be used if no code is availableFree text Performing professional 0 … 1 prsb03-dataelement-11976link The professional who identified the other risks.   Name 0 … 1 prsb03-dataelement-11977link The name of the professional.Free text.   Role 0 … 1 prsb03-dataelement-11978link The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype   Grade 0 … 1 prsb03-dataelement-11979link The grade of the professional.Free text   Speciality 0 … 1 prsb03-dataelement-11980link The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code   Professional identifier 0 … 1 prsb03-dataelement-11981link Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier Organisation 0 … 1 prsb03-dataelement-11982link The name of the organisation the professional works for.   Contact details 0 … 1 prsb03-dataelement-11983link Contact details of the professionalNHS data dictionary - UK phone number Person completing record 0 … 1 prsb03-dataelement-11984link Details of the person completing the record.   Name 0 … 1 prsb03-dataelement-11985link The name of the person completing the record.Free text.   Role 0 … 1 prsb03-dataelement-11986link The organisational role of the person completing record.FHIR value set :- SDSjobrole   Grade 0 … 1 prsb03-dataelement-11987link The grade of the person completing the record.Free text.   Specialty 0 … 1 prsb03-dataelement-11988link The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code Organisation 0 … 1 prsb03-dataelement-11989link The organisation the person completing the record works for. NHS data dictionary : - Organisation data service   Professional identifier 0 … 1 prsb03-dataelement-11990link Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier   Date completed 0 … 1 prsb03-dataelement-11991link The date and time the record was completed.Date and time.   Contact details 0 … 1 prsb03-dataelement-11992link Contact details of the person completing the record. NHS data dictionary : - UK telephone number Allergies and adverse reactions 1 … 1 prsb03-dataelement-282link Allergies and adverse reactions Allergies and adverse reactions record entry 0 … * prsb03-dataelement-10657link This is a allergies and adverse reactions record entry. There may be 1 to many record entries under a section. Each record entry is made up of a number of elements or data items.   Type of reaction 0 … 1 prsb03-dataelement-10186link The type of reaction experienced by the person (allergic, adverse, intolerance)FHIR value set :- Allergy, Intolerance Causative agent 1 … 1 Mandatory prsb03-dataelement-10182link The agent such as food, drug or substances that has caused or may cause an allergy, intolerance or adverse reaction in this person Or “No known drug allergies or adverse reactions” Or “Information not available”   Coded value 0 … 1 prsb03-dataelement-13441link The coded value for causative agent dm+d:- any code from the VTM, VMP, AMP, VMPP, AMPP and ingredient concept classes SNOMED CT : - <105590001 |Substance OR <373873005 |Pharmaceutical / biologic product| OR <<716186003 |No known allergy| OR 196461000000101 |Transfer-degraded drug allergy| OR 196471000000108 |Transfer-degraded non-drug allergy)   Free text 0 … 1 prsb03-dataelement-13442link Free text field to be used if no code is availableFree text Reaction details cluster 0 … * prsb03-dataelement-10658link Details of the reaction.   Date 0 … 1 prsb03-dataelement-10190link The date that the reaction was identified.Date and time Location 0 … 1 prsb03-dataelement-10846link Details of where the allergy was identified. Linked to the date of the diagnosis by the professional.   Coded value 0 … 1 prsb03-dataelement-13439link The coded value for location.NHS data dictionary : - Organisation data service   Free text 0 … 1 prsb03-dataelement-13440link Free text field to be used if no code is availableFree text Substance 0 … 1 prsb03-dataelement-11665link The substance, or a class of substances, that is considered to be responsible for the adverse reaction.   Coded value 0 … 1 prsb03-dataelement-13554link The coded value for substanceSNOMED CT : - <105590001 | Substance (substance) | or <373873005 | Pharmaceutical / biologic product (product) |   Free text 0 … 1 prsb03-dataelement-13555link Free text field to be used if no code is availableFree text Description of reaction 0 … 1 prsb03-dataelement-10183link A description of the manifestation of the allergic or adverse reaction experienced by the person. For example, skin rash.   Coded value 0 … 1 prsb03-dataelement-13556link The coded value for description of reaction.SNOMED CT: - ^1127581000000103 |Health issues simple reference set|   Free text 0 … 1 prsb03-dataelement-13557link Free text field to be used if no code is availableFree text   Onset date 0 … 1 prsb03-dataelement-13844link Date and time when manifestations showed e.g could be at home a few days earlier than the contactDate and time Severity 0 … 1 prsb03-dataelement-10184link A description of the severity of the reaction.   Coded value 0 … 1 prsb03-dataelement-13558link The coded value for severityFHIR value set : - Severity   Free text 0 … 1 prsb03-dataelement-13559link Free text field to be used if no code is availableFree text Certainty 0 … 1 prsb03-dataelement-10185link A description of the certainty that the stated causative agent caused the allergic or adverse reaction.   Coded value 0 … 1 prsb03-dataelement-13560link The coded value for certainty.FHIR value set : - Certainty   Free text 0 … 1 prsb03-dataelement-13561link Free text field to be used if no code is availableFree text Route of exposure 0 … 1 prsb03-dataelement-13856link The route the person was exposed to the substance   Coded value 0 … 1 prsb03-dataelement-13857link The coded value for route of exposureSNOMED CT: - ^999000051000001100 |ePrescribing route of administration simple reference set|   Free text 0 … 1 prsb03-dataelement-13858link Free text field to be used if no coded text available   Comment 0 … 1 prsb03-dataelement-10189link Any additional comment or clarification about the adverse reaction.Free text   Evidence 0 … 1 prsb03-dataelement-10187link Results of investigations that confirmed the certainty of the diagnosis. Examples might include results of skin prick allergy testsFree text   Date first experienced 0 … 1 prsb03-dataelement-10188link When the reaction was first experienced i.e this may not be the first this has happened. May be a date or partial date (e.g. year) or text (e.g. during childhood)Date and time   Allergy end date 0 … 1 prsb03-dataelement-14253link The date the allergy was diagnosed as endedDate and time    Comment 0 … 1 prsb03-dataelement-14273link Any further comments on the person's allergies or adverse reactions.Free text Performing professional 0 … 1 prsb03-dataelement-12010link The professional who identified the reaction.   Name 0 … 1 prsb03-dataelement-12011link The name of the professional.Free text.   Role 0 … 1 prsb03-dataelement-12012link The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype   Grade 0 … 1 prsb03-dataelement-12013link The grade of the professional.Free text   Speciality 0 … 1 prsb03-dataelement-12014link The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code   Professional identifier 0 … 1 prsb03-dataelement-12015link Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier Organisation 0 … 1 prsb03-dataelement-12016link The name of the organisation the professional works for.   Contact details 0 … 1 prsb03-dataelement-12017link Contact details of the professionalNHS data dictionary - UK phone number Person completing record 0 … 1 prsb03-dataelement-12018link Details of the person completing the record.   Name 0 … 1 prsb03-dataelement-12019link The name of the person completing the record.Free text.   Role 0 … 1 prsb03-dataelement-12020link The organisational role of the person completing record.FHIR value set :- SDSjobrole   Grade 0 … 1 prsb03-dataelement-12021link The grade of the person completing the record.Free text.   Specialty 0 … 1 prsb03-dataelement-12022link The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code Organisation 0 … 1 prsb03-dataelement-12023link The organisation the person completing the record works for. NHS data dictionary : - Organisation data service   Professional identifier 0 … 1 prsb03-dataelement-12024link Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier   Date completed 0 … 1 prsb03-dataelement-12025link The date and time the record was completed.Date and time.   Contact details 0 … 1 prsb03-dataelement-12026link Contact details of the person completing the record. NHS data dictionary : - UK telephone number Medications and medical devices 0 … 1 prsb03-dataelement-636link Medications and medical devices Medication item entry 0 … * prsb03-dataelement-10663link All medications and devices that can be prescribed to be entered via this Medication item entry. Handles details of continuation / addition / amendment of admission medications. Medication item cluster 0 … 1 prsb03-dataelement-10664link Medication item cluster   Date 0 … 1 prsb03-dataelement-10843link The date on which the medication or medical device was prescribed.Date and time Location 0 … 1 prsb03-dataelement-10844link The location where the medication or the medical device was prescribed.   Coded value 0 … 1 prsb03-dataelement-13620link The coded value for locationNHS data dictionary : - Organisation data service   Free text 0 … 1 prsb03-dataelement-13621link Free text field to be used if no code is availableFree text Performing professional 0 … 1 prsb03-dataelement-12002link The professional who prescribed the medication or medical device.   Name 0 … 1 prsb03-dataelement-12003link The name of the professional.Free text.   Role 0 … 1 prsb03-dataelement-12004link The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype   Grade 0 … 1 prsb03-dataelement-12005link The grade of the professional.Free text   Speciality 0 … 1 prsb03-dataelement-12006link The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code   Professional identifier 0 … 1 prsb03-dataelement-12007link Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier Organisation 0 … 1 prsb03-dataelement-12008link The name of the organisation the professional works for.   Contact details 0 … 1 prsb03-dataelement-12009link Contact details of the professionalNHS data dictionary - UK phone number Medication name 1 … 1 Mandatory prsb03-dataelement-10536link May be generic name or brand name.   Coded value 0 … 1 prsb03-dataelement-13622link The coded value for medication namedm+d:- any code from the VTM, VMP, AMP, VMPP and AMPP concept classes   Free text 0 … 1 prsb03-dataelement-13623link Free text field to be used if no code is availableFree text Form 0 … 1 prsb03-dataelement-10537link The form of the medication e.g. capsule, drops, tablet, lotion etc.   Coded value 0 … 1 prsb03-dataelement-13624link The coded value for form.SNOMED CT: - ^999000781000001107 | National Health Service dictionary of medicines and devices dose form simple reference set (foundation metadata concept) |   Free text 0 … 1 prsb03-dataelement-13625link Free text field to be used if no code is availableFree text Route 0 … 1 prsb03-dataelement-10538link The route by which the medication is administered e.g. oral, IM, IV   Coded value 0 … 1 prsb03-dataelement-13655link The coded value for routeSNOMED CT: - ^999000051000001100 |ePrescribing route of administration simple reference set (foundation metadata concept)|   Free text 0 … 1 prsb03-dataelement-13656link Free text field to be used if no code is availableFree text Site 0 … 1 prsb03-dataelement-10540link The anatomical site at which the medication is to be administered.   Coded value 0 … 1 prsb03-dataelement-13657link The coded value for siteSNOMED CT: - <442083009 | Anatomical or acquired body structure (body structure) |   Free text 0 … 1 prsb03-dataelement-13658link Free text field to be used when code is not availableFree text Method 0 … 1 prsb03-dataelement-10541link The technique or method by which the medication is to be administered.   Coded value 0 … 1 prsb03-dataelement-13845link The coded value for methodSNOMED CT : - ^999000041000001103 | ePrescribing method simple reference set (foundation metadata concept) |   Free text 0 … 1 prsb03-dataelement-13846link Free text field to be used if no coded text available   Over the counter medication flag 0 … 1 prsb03-dataelement-13379link Indicates if the medication or device is acquired without a prescription i.e. got by the person over the counterFlag : - Yes or No Structured dose direction cluster 0 … 1 prsb03-dataelement-11639link A structural representation of the elements carried by the dose syntax in 'parsable dose strength / timing' i.e. dose strength, dose timing, dose duration and maximum dose. Structured dose amount 0 … 1 prsb03-dataelement-10554link A structural representation of dose amount, e.g. 20mg or 2 tablets. This element will generally only be used when persisting data within systems with 'parsable dose directions' being used to exchange the same information between systems. As per FHIR Dose Syntax Implementation Guidance (NHS Digital): https://simplifier.net/guide/DoseSyntaxImplementationGuidanceforFHIRR4/Home   Structured dose timing 0 … 1 prsb03-dataelement-10555link A slot containing a structural, computable representation of dose timing and maximum dose. This element will generally only be used when persisting data within systems with 'parsable dose directions' being used to exchange the same information between systems. As per FHIR Dose Syntax Implementation Guidance (NHS Digital): https://simplifier.net/guide/DoseSyntaxImplementationGuidanceforFHIRR4/Home Numeric   Dose direction duration 0 … 1 prsb03-dataelement-10548link Recommendation of the time period for which the medication should be continued, including direction not to discontinue. As per FHIR Dose Syntax Implementation Guidance (NHS Digital): https://simplifier.net/guide/DoseSyntaxImplementationGuidanceforFHIRR4/Home Numeric   Dose directions description 0 … 1 prsb03-dataelement-10544link Describes the entire medication dosage and administration directions including dose quantity and medication frequency and optionally duration e.g. “1 tablet at night" or “2mg at 10pm”.Free text   Additional instructions 0 … 1 prsb03-dataelement-10545link Allows for: requirements for adherence support, e.g. compliance aids, prompts and packaging requirements, additional information about specific medicines e.g. where specific brand required, person requirements, e.g. unable to swallow tablets.FHIR value set : - Additional instruction Course details cluster 0 … 1 prsb03-dataelement-10561link Details of the overall course of medication.   Course status 0 … 1 prsb03-dataelement-10666link The status of this prescription.FHIR value set : - Medication status   Indication 0 … 1 prsb03-dataelement-10546link Reason for medication being prescribed, where known.Free text   Start date/time 0 … 1 prsb03-dataelement-10667link The date and/or time that the medication course should begin.Date and time   End date/time 0 … 1 prsb03-dataelement-10557link The date and/or time that the medication course should finish.Date and time   Link to indication record 0 … 1 prsb03-dataelement-10668link A link to the record which contains the indication for this medication order.Free text with URL   Comment/recommendation 0 … 1 prsb03-dataelement-10547link Suggestions about duration and/or review, ongoing monitoring requirements, advice on starting, discontinuing or changing medication. Additional comment or recommendation about the medication course e.g. 'Patient named supply', 'unlicensed medication', 'Foreign brand' or monitoring recommendationsFree text Medication change summary cluster 0 … 1 prsb03-dataelement-10568link Records the changes made to medication.   Status 0 … 1 prsb03-dataelement-10669link The nature of any change made to the medication.FHIR value set : Medication status   Indication 0 … 1 prsb03-dataelement-10670link Reason for change in medication, e.g. sub-therapeutic dose, person intolerant. SNOMED CT:- ^1127601000000107 | Healthcare matters simple reference set (foundation metadata concept) |   Date of change 0 … 1 prsb03-dataelement-10671link The date of the change - addition, or amendmentDate and time   Description of amendment 0 … 1 prsb03-dataelement-10672link Where a change is made to the medication i.e. one drug stopped and another started or eg dose, frequency or route is changed.Free text   Total dose daily quantity 0 … 1 prsb03-dataelement-10665link The total daily dose of this medication. This is helpful for estimating optimal adherence to dosing guidance. It may be computed from product/dose strength and frequency or entered manually.Free text Person completing record 0 … 1 prsb03-dataelement-11993link Details of the person completing the record.   Name 0 … 1 prsb03-dataelement-11994link The name of the person completing the record.Free text.   Role 0 … 1 prsb03-dataelement-11995link The organisational role of the person completing record.FHIR value set :- SDSjobrole   Grade 0 … 1 prsb03-dataelement-11996link The grade of the person completing the record.Free text.   Specialty 0 … 1 prsb03-dataelement-11997link The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code Organisation 0 … 1 prsb03-dataelement-11998link The organisation the person completing the record works for. NHS data dictionary : - Organisation data service   Professional identifier 0 … 1 prsb03-dataelement-11999link Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier   Date completed 0 … 1 prsb03-dataelement-12000link The date and time the record was completed.Date and time.   Contact details 0 … 1 prsb03-dataelement-12001link Contact details of the person completing the record. NHS data dictionary : - UK telephone number Medical devices entry 0 … * prsb03-dataelement-10583link Medical devices   Medical device 0 … 1 prsb03-dataelement-10673link Any medical device that isn't prescribed.Free text   Comments 0 … 1 prsb03-dataelement-11280link Any information regarding the medical device.Free text Medication discontinued entry 0 … * prsb03-dataelement-10576link Medication discontinued entry Name of discontinued medication 1 … 1 Mandatory prsb03-dataelement-10577link The name of the medication or medical device being discontinued   Coded value 0 … 1 prsb03-dataelement-13659link The coded value for medication name dm+d:- any code from the VTM, VMP, AMP, VMPP and AMPP concept classes   Free text 0 … 1 prsb03-dataelement-13660link Amount of vaccine administered.Free text   Status 1 … 1 Mandatory prsb03-dataelement-12472link The status of any change made to the medication. MUST CONTAIN STOPPED.FHIR value set: - Medication status   Indication 0 … 1 prsb03-dataelement-10579link The clinical indication for any changes in medication status SNOMED CT:- ^1127601000000107 | Healthcare matters simple reference set (foundation metadata concept) |   Date of change 0 … 1 prsb03-dataelement-10580link The date of the discontinuationDate and time   Comment 0 … 1 prsb03-dataelement-10582link Any additional comment about the discontinuation or amendment.Free text Information and advice given 1 … 1 Mandatory prsb03-dataelement-315link Information and advice given   Information and advice given 1 … 1 Mandatory prsb03-dataelement-10215link The oral or written information or advice given to the patient, carer, other authorised representative, care professional or other third party. May include advice about actions related to medicines or other ongoing care activities on an ‘information prescription'. State here if there are concerns about the extent to which the patient and/or carer understand the information provided about diagnosis, prognosis and treatment. Free text Contact for further information 1 … 1 Mandatory prsb03-dataelement-329link Contact for further information Contact for further information record entry 0 … * prsb03-dataelement-10659link This is a Contact for further information record entry. There may be 1 to many record entries under a section. Each record entry is made up of a number of elements or data items.   Contact for further information 1 … 1 Mandatory prsb03-dataelement-10229link The contact details of whom to contact for information regarding this attendance. The contact details may be for an individual or team (for example a phone number for the emergency department administrator).Free text Plan and requested actions 1 … 1 Mandatory prsb03-dataelement-535link The details of planned investigations, procedures and treatment, and whether this plan has been agreed with the person or their legitimate representative. Plan and requested actions record entry 0 … * prsb03-dataelement-10661link This is a plan and requested actions record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.   Date 0 … 1 prsb03-dataelement-10445link The date on which the plan and requested actions were prepared.Date and time Performing professional 0 … 1 prsb03-dataelement-12167link The professional who prepared the plan and requested actions.   Name 0 … 1 prsb03-dataelement-12168link The name of the professional.Free text.   Role 0 … 1 prsb03-dataelement-12169link The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etcFHIR value set :- SDSjobroletype   Grade 0 … 1 prsb03-dataelement-12170link The grade of the professional.Free text   Speciality 0 … 1 prsb03-dataelement-12171link The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code   Professional identifier 0 … 1 prsb03-dataelement-12172link Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier Organisation 0 … 1 prsb03-dataelement-12173link The name of the organisation the professional works for.   Contact details 0 … 1 prsb03-dataelement-12174link Contact details of the professionalNHS data dictionary - UK phone number Location 0 … 1 prsb03-dataelement-10842link The location where the plan and requested actions were prepared.   Coded value 0 … 1 prsb03-dataelement-13684link The coded value for locationNHS data dictionary : - Organisation data service   Free text 0 … 1 prsb03-dataelement-13685link Free text field to be used if no code is availableFree text   Actions for professionals 1 … 1 Mandatory prsb03-dataelement-10436link Including planned investigations, procedures and treatment for a person's identified conditions and priorities. For each action the following should be identified:outcome expectations, including the person’s expectations. A record of the planned and requested actions. May be structured (table), with actions, names, dates, status, location, strategies.Free text   Actions for person or their carer 1 … 1 Mandatory prsb03-dataelement-10437link For each action the following should be identified:outcome expectations, including person’s expectations. A record of the planned and requested actions. May be structured (table), with actions, names, dates, status, location, strategies.Free text   Agreed with the person or their legitimate representative 0 … 1 prsb03-dataelement-10438link Indicates whether the person or their legitimate representative has agreed the entire plan or individual aspects of treatment, expected outcomes, risks and alternative treatments. A record of the agreement of the decisions made.Free text   Outcome of plan and requested actions 0 … * prsb03-dataelement-10950link The details of the outcome of the plan and requested actions.Free text. Person completing record 0 … 1 prsb03-dataelement-12175link Details of the person completing the record.   Name 0 … 1 prsb03-dataelement-12176link The name of the person completing the record.Free text.   Role 0 … 1 prsb03-dataelement-12177link The organisational role of the person completing record.FHIR value set :- SDSjobrole   Grade 0 … 1 prsb03-dataelement-12178link The grade of the person completing the record.Free text.   Specialty 0 … 1 prsb03-dataelement-12179link The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code Organisation 0 … 1 prsb03-dataelement-12180link The organisation the person completing the record works for. NHS data dictionary : - Organisation data service   Professional identifier 0 … 1 prsb03-dataelement-12181link Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier   Date completed 0 … 1 prsb03-dataelement-12182link The date and time the record was completed.Date and time.   Contact details 0 … 1 prsb03-dataelement-12183link Contact details of the person completing the record. NHS data dictionary : - UK telephone number Person completing record 1 … 1 Mandatory prsb03-dataelement-12605link Details of the person completing the record.   Name 1 … 1 Mandatory prsb03-dataelement-12606link The name of the person completing the record.Free text.   Role 1 … 1 prsb03-dataelement-12607link The organisational role of the person completing record.FHIR value set :- SDSjobrole   Grade 0 … 1 prsb03-dataelement-12608link The grade of the person completing the record.Free text.   Specialty 0 … 1 prsb03-dataelement-12609link The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code Organisation 1 … 1 prsb03-dataelement-12610link The organisation the person completing the record works for. NHS data dictionary : - Organisation data service   Professional identifier 0 … 1 prsb03-dataelement-12611link Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier   Date completed 1 … 1 Mandatory prsb03-dataelement-12612link The date and time the record was completed.Date and time.   Contact details 0 … * prsb03-dataelement-12613link Contact details of the person completing the record. NHS data dictionary : - UK telephone number Senior Reviewing Clinician 1 … 1 Mandatory prsb03-dataelement-15133link The details of the senior clinician who reviewed the record.   Name 1 … 1 Mandatory prsb03-dataelement-15140link The name of the senior clinician responsible for reviewing the treatment and discharge plan. The person name as held on the source system. Where possible this should be broken down into its constituent parts NHS data dictionary - Person Full Name    Professional identifier 0 … 1 prsb03-dataelement-15141link Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation. NHS data dictionary :-  Professional registration identifier