| Concept |
Card/Conf |
Id |
 |
Person demographics |
|
1 … 1 Mandatory |
prsb03-dataelement-10868 link |
|
The person's details and contact information. |
 |
|
Person name |
|
1 … 1 Mandatory |
prsb03-dataelement-10869 link |
|
Details of the person's name |
|
|
1 … * Mandatory |
prsb03-dataelement-13799 link |
|
The first name(s) of the person. This includes middle names.NHS data dictionary :- Person given name
|
|
|
1 … * Mandatory |
prsb03-dataelement-13800 link |
|
The family name or surname of the personNHS data dictionary : - Person family name
|
|
|
0 … 1 |
prsb03-dataelement-10870 link |
|
The name by which a person wishes to be addressed. The preferred name volunteered
by the person or a preferred name given by PDS that the person has asked to be called
by.NHS data dictionary: - Person full name
|
|
|
0 … 1 |
prsb03-dataelement-13089 link |
|
Person's titleNHS data dictionary: - Person title
|
|
|
0 … * |
prsb03-dataelement-13798 link |
|
A textual suffix that may be added to the end of a PERSON's name, for example, OBE,
MBE, BSc, JP, GMNHS data dictionary: - Person suffix
|
|
|
0 … 1 |
prsb03-dataelement-13801 link |
|
The full name of the person in text representation.NHS data dictionary :- Person full name
|
|
|
Date of birth |
|
1 … 1 Mandatory |
prsb03-dataelement-10871 link |
|
The date of birth of the person.NHS data dictionary:- Person birth date
|
|
|
Gender |
|
0 … 1 |
prsb03-dataelement-10872 link |
|
The person's stated gender.NHS data dictionary :- Person stated gender code
|
|
|
Ethnicity |
|
0 … 1 |
prsb03-dataelement-10874 link |
|
The ethnicity of the person as specified by the person.NHS data dictionary :- Ethnic category
|
|
|
Religion |
|
0 … 1 |
prsb03-dataelement-10876 link |
|
The religious affiliation as specified by the person.
SNOMED_CT:- Religion
|
|
|
Sex |
|
0 … 1 |
prsb03-dataelement-10877 link |
|
The person’s phenotypic sex. Determines how the person will be treated clinically.NHS data dictionary: - person phenotypic sex
|
|
|
NHS number |
|
0 … 1 |
prsb03-dataelement-10879 link |
|
The unique identifier for a person within the NHS in England and Wales.NHS data dictionary:- NHS number
|
|
|
NHS number status indicator |
|
0 … 1 |
prsb03-dataelement-13297 link |
|
Provides an indication of the reliability of an NHS Number.NHS data dictionary :- NHS number status indicator
|
|
|
Other identifier |
|
0 … * |
prsb03-dataelement-10880 link |
|
Country specific or local identifier, e.g. Community Health Index (CHI) in Scotland.
NHS data dictionary: - Local patient identifier(extended), Health and care number
(NI only), Community health index number (Scotland only)
|
|
|
Person's address |
|
1 … * Mandatory |
prsb03-dataelement-10881 link |
|
Person’s usual place of residence, and where relevant temporary and correspondence
addresses.
|
|
|
1 … 1 Mandatory |
prsb03-dataelement-13082 link |
|
Person's first line of address.
NHS data dictionary :- Address line 1
|
|
|
0 … 1 |
prsb03-dataelement-13083 link |
|
Person's second line of address.
NHS data dictionary :- Address line 2
|
|
|
0 … 1 |
prsb03-dataelement-13084 link |
|
Person's third line of address.
NHS data dictionary : - Address line 3
|
|
|
0 … 1 |
prsb03-dataelement-13085 link |
|
Person's fourth line of address.
NHS data dictionary : - Address line 4
|
|
|
0 … 1 |
prsb03-dataelement-13086 link |
|
Person's fifth line of address.NHS data dictionary : - Address line 5
|
|
|
0 … 1 |
prsb03-dataelement-13087 link |
|
The person's postcode.NHS data dictionary :- Postcode of usual address
|
|
|
0 … 1 |
prsb03-dataelement-13221 link |
|
The type of address e.g. Main address, Temp addressNHS data dictionary : - Address association type
|
|
|
Person's contact details |
|
0 … 1 |
prsb03-dataelement-13804 link |
|
Details of the person's contact information. |
|
|
0 … 1 |
prsb03-dataelement-10886 link |
|
Preferred contact method, e.g. email, letter, phone, text message etc.NHS data dictionary :- Communication contact method
|
 |
|
|
Person's telephone number details |
|
0 … * |
prsb03-dataelement-10883 link |
|
The person's telephone number details |
|
|
|
|
Person's telephone number |
|
0 … 1 |
prsb03-dataelement-13808 link |
|
The person's telephone numberNHS data dictionary : - UK telephone number
|
|
|
|
|
Person's telephone number type |
|
0 … 1 |
prsb03-dataelement-13805 link |
|
The contact type e.g. home, mobileFHIR value set: - Contact point use
|
|
|
|
|
Preference of telephone number |
|
0 … 1 |
prsb03-dataelement-13809 link |
|
The preferred order of use for the telephone numberPreference of use 1-5, 1 being the highest. |
|
|
|
Person's email address details |
|
0 … * |
prsb03-dataelement-13807 link |
|
Details of the person's email address |
|
|
0 … 1 |
prsb03-dataelement-10882 link |
|
Email address of the person.NHS data dictionary :- Contact email address
|
|
|
|
|
Person's email address type |
|
0 … 1 |
prsb03-dataelement-13811 link |
|
The type of email address, home, workFHIR value set: - Contact point use
|
|
|
|
|
Preference of email address |
|
0 … 1 |
prsb03-dataelement-13810 link |
|
The preferred order of use of email addressPreference of use 1-5, 1 being the highest. |
|
|
|
Other contact information |
|
0 … 1 |
prsb03-dataelement-13806 link |
|
Contact details via fax, sms, urlNHS data dictionary:- Communication contact string
|
|
|
Organ and tissue donation |
|
0 … 1 |
prsb03-dataelement-13847 link |
|
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-10911 link |
|
If the person is a child, name and address of where the child attends, eg play group,
nursery, school.Free text or ODS code where available.
|
|
GP practice |
|
1 … 1 Mandatory |
prsb03-dataelement-101 link |
|
Details of the person's GP practice. |
|
|
GP practice record entry |
|
0 … * |
prsb03-dataelement-10643 link |
|
This is an GP practice record entry. There may be 0 to many record entries under a
section. Each record entry is made up of a number of elements or data items
|
|
|
0 … 1 |
prsb03-dataelement-10003 link |
|
The name of the person's GP. If the person is registered with a GP practice, their
usual GP name will be something volunteered by the person or their representative.Free text
|
|
|
0 … 1 |
prsb03-dataelement-10002 link |
|
Name and address of the person's registered GP practice Registered GP practice details
are available from the Person Demographics Service (PDS), or volunteered from the
person or their representative. Include details of the practice name and address.Free text
|
|
|
1 … 1 Mandatory |
prsb03-dataelement-10001 link |
|
The identifier of the registered GP practice.
NHS data dictionary : - General medical practice code (patient registration)
|
|
About me |
|
0 … 1 |
prsb03-dataelement-466 link |
|
About me |
|
|
What is most important to me |
|
0 … 1 |
prsb03-dataelement-12964 link |
|
A description of what is most important to you.
|
|
|
|
What is most important to me |
|
0 … 1 |
prsb03-dataelement-14325 link |
|
A description of what is most important to you
Emergency Information : - Include any essential information that any professional in health and social care
should know about the you in any situation, including emergencies.
Other Information : -This could include : - Values, Spirituality/religion, Ethnicity, Culture, Pets, Goals
and aspirations, Meaningful activities including leisure activities, visiting places,
sport and exercise, listening to music, employment, education, volunteeringFree text
|
|
|
People who are important to me |
|
0 … 1 |
prsb03-dataelement-13009 link |
|
Details of who is important to you and why. |
|
|
|
People who are important to me |
|
0 … 1 |
prsb03-dataelement-14327 link |
|
Details of who is important to you and why. They could be family members, carers,
friends, members of staff etc. Include how you want the people important to you to
be engaged and involved in your care and support in both emergency and normal situations.
Include how you stay connected to the people important to you. Who should not be contacted
or consulted about your care and support and why, if you wish to sayFree text
|
|
|
How I communicate and how to communicate with me |
|
0 … 1 |
prsb03-dataelement-13006 link |
|
A description of how you communicate normally. |
|
|
|
How I communicate and how to communicate with me |
|
0 … 1 |
prsb03-dataelement-14329 link |
|
A description of how you communicate normally including any communication aids you
use, for example a hearing aid.
- Include your preferred language of communication, if your first language is not English.
- Include how you would communicate when you are in pain or distress.
- Include how you communicate choices.
- Include how you give feedback or raise a concern.
- Include how you like to receive information
Describe how you would like others to engage and communicate with you, including how
you would like to be addressed.
Free text
|
|
|
My wellness |
|
0 … 1 |
prsb03-dataelement-13005 link |
|
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.
|
|
|
0 … 1 |
prsb03-dataelement-14331 link |
|
Free text
|
|
|
Please do and please don't |
|
0 … 1 |
prsb03-dataelement-13008 link |
|
A description of things you want someone supporting you to do (or not to do). |
|
|
|
Please do and please don't |
|
0 … 1 |
prsb03-dataelement-14333 link |
|
A description of things you want someone supporting you to do (or not to do).
Things you want someone to do might include (for example): - Talk to me not to my carer, remind me to take my medication,
encourage me to wash my hands regularly, explain to me what is happening and why,
respond to my communication.
A description of things you do not want someone supporting you to do might include (for example): - Discussing or asking
questions about certain topics, making assumptions about something, providing support
when it is not wanted, talking to you in a certain way, undergoing a specific intervention
or taking a medication the person does not want.Free text
|
|
|
How and when to support me |
|
0 … 1 |
prsb03-dataelement-13007 link |
|
A description of how and when you want someone caring for you to support you. |
|
|
|
How and when to support me |
|
0 … 1 |
prsb03-dataelement-14335 link |
|
A description of how and when you want someone caring for you to support you.
- This could include support needs in an emergency situation (for example taking blood)
- This could include support you need to maintain important routines or to carry out
particular activities, for example: - Personal care routines, Eating and drinking,
Bedtime routines, Taking medications, Moving and transitioning
- This could also include support needed with:- wearing glasses/hearing aids/false teeth
etc, making informed choices or understanding dangers and risks, managing your emotions,
moods and behaviours, memory or confusion.
- Include how your support needs change in different environments. Include any triggers
that might result in you needing further support and strategies for avoiding or addressing
the triggers. Include how you want the support to be provided.
Free text
|
|
|
Also worth knowing about me |
|
0 … 1 |
prsb03-dataelement-13094 link |
|
A description of what is also worth knowing about you for people caring or supporting
you.
|
|
|
|
Also worth knowing about me |
|
0 … 1 |
prsb03-dataelement-14337 link |
|
A description of what is also worth knowing about you for people caring or supporting
you.
- This could include a short history of your life (where you have worked, where you
lived, important events in your life, important people in your past life).
- This could include a short profile of your current life:- your work / study, your
aspirations, your skills, your networks, things you like e.g. particular foods, places,
a football team and things you like to talk about, things you dislike
- This could also include any care and support preferences that have not been included
elsewhere.
Free text
|
|
|
Date |
|
0 … 1 |
prsb03-dataelement-10367 link |
|
This is a record of the date that this information was last updated.Date and Time |
|
|
Supported to write this by |
|
0 … 1 |
prsb03-dataelement-10368 link |
|
Where relevant, this is a record of name, relationship/role and contact details of
the individual who supported the person to write this section e.g. carer, family member,
advocate, professional.Free text
|
|
|
Location to multimedia file |
|
0 … 1 |
prsb03-dataelement-14326 link |
|
The link to the person's multimedia fileLink to URL |
|
Individual requirements |
|
0 … 1 |
prsb03-dataelement-160 link |
|
The individual requirements of the person. |
|
|
Reasonable adjustment |
|
0 … 1 |
prsb03-dataelement-12991 link |
|
A record of reasonable adjustments that must be provided by the service to comply
with the Equality Act 2010.
|
|
|
|
Reasonable adjustment record entry |
|
0 … * |
prsb03-dataelement-13061 link |
|
This is a reasonable adjustment record entry. There may be 0 to many record entries
under a section. Each record entry is made up of a number of elements or data items
|
|
|
0 … 1 |
prsb03-dataelement-13098 link |
|
The location where the reasonable adjustment was identified. |
|
|
0 … 1 |
prsb03-dataelement-13357 link |
|
The coded value for location.NHS Data dictionary : - Organisation data service code
|
|
|
0 … 1 |
prsb03-dataelement-13358 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-13017 link |
|
The reasonable adjustment required e.g. requires specific contact method, requires
communication professional
|
|
|
0 … 1 |
prsb03-dataelement-13505 link |
|
The coded value for reasonable adjustmentSNOMED CT : - Accessible information standard^999002121000000109 |Accessible information
- communication support simple reference set (foundation metadata concept)|^999002151000000104
|Accessible information - requires communication professional simple reference set
(foundation metadata concept)|^999002131000000106 |Accessible information - requires
specific contact method simple reference set (foundation metadata concept)|^999002141000000102
|Accessible information - requires specific information format simple reference set
(foundation metadata concept)|Refsets for other categories in development
|
|
|
0 … 1 |
prsb03-dataelement-13506 link |
|
Free text field to be used if no code is availableFree text |
|
|
|
|
Reasonable adjustment additional detail |
|
0 … 1 |
prsb03-dataelement-13018 link |
|
Further detail about the support required and the consequence of not providing it.Free text |
|
|
0 … 1 |
prsb03-dataelement-13020 link |
|
The date the reasonable adjustment was identified.Date and time |
|
|
0 … 1 |
prsb03-dataelement-13027 link |
|
The professional who confirmed the need for the reasonable adjustment. |
|
|
0 … 1 |
prsb03-dataelement-13028 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-13029 link |
|
The role the professional has in relation to the person.FHIR value set : - sdsjobrole
|
|
|
0 … 1 |
prsb03-dataelement-13030 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-13031 link |
|
The specialty of the professional.NHS data dictionary - Main specialty code
|
|
|
0 … 1 |
prsb03-dataelement-13032 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-13033 link |
|
The name of the organisation the professional works for. |
|
|
0 … 1 |
prsb03-dataelement-13034 link |
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
|
0 … 1 |
prsb03-dataelement-13035 link |
|
A record of the details of the person that entered the reasonable adjustment and the
date on which it was entered.
|
|
|
0 … 1 |
prsb03-dataelement-13036 link |
|
The name of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-13037 link |
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
|
0 … 1 |
prsb03-dataelement-13038 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-13039 link |
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-13040 link |
|
The organisation the person completing the record works for.
NHS data dictionary : -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-13041 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-13042 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-13043 link |
|
Contact details of the person completing the record.
NHS data dictionary : - UK telephone number
|
|
|
Impairment |
|
0 … 1 |
prsb03-dataelement-13001 link |
|
A record of any impairments for the person relating to reasonable adjustments. |
|
|
0 … * |
prsb03-dataelement-13062 link |
|
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
|
|
|
0 … 1 |
prsb03-dataelement-13099 link |
|
The location where the impairment was identified. |
|
|
0 … 1 |
prsb03-dataelement-13429 link |
|
The coded value for location.NHS data dictionary: - Organisation code service
|
|
|
0 … 1 |
prsb03-dataelement-13430 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-13022 link |
|
The category of the impairment e.g. Autism, Dementia, Physical disability, Sensory
disability - such as sight or hearing, Long-term condition
|
|
|
0 … 1 |
prsb03-dataelement-13507 link |
|
The coded value for impairment.SNOMED CT |
|
|
0 … 1 |
prsb03-dataelement-13508 link |
|
Free text field to be used if no code is availableFree text |
|
|
|
|
Impairment additional detail |
|
0 … 1 |
prsb03-dataelement-13023 link |
|
Description of what the person can do with the impairment, what they want to be able
to do and how they should be supported to do it and what the consequences are of not
providing the support.
Where there is a sensory disability include sensory processing difficulties (e.g.
affects to balance and movement, oversensitive, under-sensitive).
Free text
|
|
|
0 … 1 |
prsb03-dataelement-13024 link |
|
The date the impairment was identified.Date and time |
|
|
0 … 1 |
prsb03-dataelement-13044 link |
|
The professional who confirmed the impairment. |
|
|
0 … 1 |
prsb03-dataelement-13045 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-13046 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
|
0 … 1 |
prsb03-dataelement-13047 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-13048 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-13049 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-13050 link |
|
The name of the organisation the professional works for. |
|
|
0 … 1 |
prsb03-dataelement-13051 link |
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
|
0 … 1 |
prsb03-dataelement-13052 link |
|
A record of the details of the person that entered the impairment and the date on
which it was entered.
|
|
|
0 … 1 |
prsb03-dataelement-13053 link |
|
The name of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-13054 link |
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
|
0 … 1 |
prsb03-dataelement-13055 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-13056 link |
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-13057 link |
|
The organisation the person completing the record works for.
NHS data dictionary : -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-13058 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-13059 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-13060 link |
|
Contact details of the person completing the record.
NHS data dictionary : - UK telephone number
|
|
|
Cognition |
|
0 … * |
prsb03-dataelement-10066 link |
|
Details of the persons cognitive impairment. |
|
|
0 … 1 |
prsb03-dataelement-11705 link |
|
The date when the cognitive impairment was identified.Date and time |
|
|
0 … 1 |
prsb03-dataelement-11706 link |
|
The location where the cognitive impairment was identified. |
|
|
0 … 1 |
prsb03-dataelement-13431 link |
|
The coded value for location.NHS data dictionary : - Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-13432 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-13669 link |
|
The cognitive impairment to be considered when communicating with the person, child
or their primary carer.Free text
|
|
|
0 … 1 |
prsb03-dataelement-11470 link |
|
The professional who identified the cognitive impairment. |
|
|
0 … 1 |
prsb03-dataelement-11471 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11472 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
|
0 … 1 |
prsb03-dataelement-11473 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-11474 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-11475 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-11476 link |
|
The name of the organisation the professional works for. |
|
|
0 … * |
prsb03-dataelement-11477 link |
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
|
0 … 1 |
prsb03-dataelement-11478 link |
|
Details of the person completing the record. |
|
|
0 … 1 |
prsb03-dataelement-11479 link |
|
The name of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11480 link |
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
|
0 … 1 |
prsb03-dataelement-11481 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11482 link |
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-11483 link |
|
The organisation the person completing the record works for.
NHS data dictionary : -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-11484 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-11485 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … * |
prsb03-dataelement-11486 link |
|
Contact details of the person completing the record.
NHS data dictionary : - UK telephone number
|
|
|
Mobility |
|
0 … * |
prsb03-dataelement-10067 link |
|
Details of the person's mobility needs. |
|
|
0 … 1 |
prsb03-dataelement-11707 link |
|
The date when the mobility needs were identified.Date and time |
|
|
0 … 1 |
prsb03-dataelement-11710 link |
|
The location where the mobility needs were identified. |
|
|
0 … 1 |
prsb03-dataelement-13433 link |
|
The coded value for location.NHS data dictionary : - Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-13434 link |
|
Free text field to be used if no coded text available |
|
|
0 … 1 |
prsb03-dataelement-13670 link |
|
The mobility needs of the person that allows movement between two spaces and achieves
participation and a degree of independence.
|
|
|
0 … 1 |
prsb03-dataelement-13671 link |
|
The coded value for mobility needsSNOMED CT: - ^999002551000000108 |Mobility findings simple reference set (foundation
metadata concept)|
|
|
|
0 … 1 |
prsb03-dataelement-13672 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-11487 link |
|
The professional who identified the mobility needs. |
|
|
0 … 1 |
prsb03-dataelement-11488 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11489 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
|
0 … 1 |
prsb03-dataelement-11490 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-11491 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-11492 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-11493 link |
|
The name of the organisation the professional works for. |
|
|
0 … * |
prsb03-dataelement-11494 link |
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
|
0 … 1 |
prsb03-dataelement-11495 link |
|
Details of the person completing the record. |
|
|
0 … 1 |
prsb03-dataelement-11496 link |
|
The name of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11497 link |
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
|
0 … 1 |
prsb03-dataelement-11498 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11499 link |
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-11500 link |
|
The organisation the person completing the record works for.
NHS data dictionary : -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-11501 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-11502 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … * |
prsb03-dataelement-11503 link |
|
Contact details of the person completing the record.
NHS data dictionary : - UK telephone number
|
|
|
Other individual requirements |
|
0 … * |
prsb03-dataelement-10835 link |
|
Details of any other individual requirements the person may have |
|
|
0 … 1 |
prsb03-dataelement-11711 link |
|
The date when the other individual requirements were identified.Date and time |
|
|
0 … 1 |
prsb03-dataelement-11712 link |
|
The location where the other individual requirements were identified. |
|
|
0 … 1 |
prsb03-dataelement-13435 link |
|
The coded value for location.NHS data dictionary : - Organisation service code
|
|
|
0 … 1 |
prsb03-dataelement-13436 link |
|
Free text field to be used if no coded text available |
|
|
|
Other individual requirement |
|
0 … 1 |
prsb03-dataelement-13673 link |
|
Other individual requirements that a person may have.Free text |
|
|
0 … 1 |
prsb03-dataelement-11504 link |
|
The professional who identified the other individual requirements. |
|
|
0 … 1 |
prsb03-dataelement-11505 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11506 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
|
0 … 1 |
prsb03-dataelement-11507 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-11508 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-11509 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-11510 link |
|
The name of the organisation the professional works for. |
|
|
0 … * |
prsb03-dataelement-11511 link |
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
|
0 … 1 |
prsb03-dataelement-11512 link |
|
Details of the person completing the record. |
|
|
0 … 1 |
prsb03-dataelement-11513 link |
|
The name of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11514 link |
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
|
0 … 1 |
prsb03-dataelement-11515 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11516 link |
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-11517 link |
|
The organisation the person completing the record works for.
NHS data dictionary : -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-11518 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-11519 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … * |
prsb03-dataelement-11520 link |
|
Contact details of the person completing the record.
NHS data dictionary : - UK telephone number
|
|
Legal information |
|
0 … 1 |
prsb03-dataelement-520 link |
|
The legal information relating to the person. |
|
|
Consent for information sharing |
|
0 … 1 |
prsb03-dataelement-10421 link |
|
Details of the person's consent for information sharing |
|
|
0 … 1 |
prsb03-dataelement-11713 link |
|
The date when the consent was givenDate and time |
|
|
0 … 1 |
prsb03-dataelement-11714 link |
|
The location where the consent was taken. |
|
|
0 … 1 |
prsb03-dataelement-13451 link |
|
The coded value for location.NHS data dictionary : - Organisation data service code
|
|
|
0 … 1 |
prsb03-dataelement-13452 link |
|
Free text field to be used if no code is availableFree text |
|
|
|
Consent for information sharing |
|
0 … 1 |
prsb03-dataelement-13575 link |
|
This is a record of consent for information sharing under the common law duty of confidentiality.
Where consent has not been obtained or sought, the reason why should be provided.
Include best interests decision where person lacks capacity. This is a placeholder
until the national guidance is published.Free text
|
|
|
|
Reason for consent not given |
|
0 … 1 |
prsb03-dataelement-13778 link |
|
Reason not given for consentFree text |
|
|
0 … 1 |
prsb03-dataelement-11715 link |
|
The professional who took the consent for information sharing |
|
|
0 … 1 |
prsb03-dataelement-11716 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11717 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
|
0 … 1 |
prsb03-dataelement-11718 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-11719 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-11720 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-11721 link |
|
The name of the organisation the professional works for. |
|
|
0 … 1 |
prsb03-dataelement-11722 link |
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
|
0 … 1 |
prsb03-dataelement-11723 link |
|
Details of the person completing the record. |
|
|
0 … 1 |
prsb03-dataelement-11724 link |
|
The name of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11725 link |
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
|
0 … 1 |
prsb03-dataelement-11726 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11727 link |
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-11728 link |
|
The organisation the person completing the record works for.
NHS data dictionary : -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-11729 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-11730 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-11731 link |
|
Contact details of the person completing the record.
NHS data dictionary : - UK telephone number
|
|
|
Consent relating to child |
|
0 … * |
prsb03-dataelement-10422 link |
|
Details of the person's consent relating to child |
|
|
0 … 1 |
prsb03-dataelement-11732 link |
|
The date when the person with responsibility for the child was identified.Date and time |
|
|
0 … 1 |
prsb03-dataelement-11733 link |
|
The location where the person with responsibility for the child was identified. |
|
|
0 … 1 |
prsb03-dataelement-13674 link |
|
The coded value for locationNHS data dictionary : - Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-13675 link |
|
Free text field to be used if no coded text available |
|
|
|
Consent relating to child |
|
0 … 1 |
prsb03-dataelement-13576 link |
|
The person with parental responsibility or appointed guardian where a child lacks
competency. Consideration of age and competency, applying Gillick competency or Fraser
guidelines.Free text
|
|
|
0 … 1 |
prsb03-dataelement-11734 link |
|
The professional who identified the person responsible for the child. |
|
|
0 … 1 |
prsb03-dataelement-11735 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11736 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
|
0 … 1 |
prsb03-dataelement-11737 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-11738 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-11739 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-11740 link |
|
The name of the organisation the professional works for. |
|
|
0 … 1 |
prsb03-dataelement-11741 link |
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
|
0 … 1 |
prsb03-dataelement-11742 link |
|
Details of the person completing the record. |
|
|
0 … 1 |
prsb03-dataelement-11743 link |
|
The name of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11744 link |
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
|
0 … 1 |
prsb03-dataelement-11745 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11746 link |
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-11747 link |
|
The organisation the person completing the record works for.
NHS data dictionary : -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-11748 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-11749 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-11750 link |
|
Contact details of the person completing the record.
NHS data dictionary : - UK telephone number
|
|
|
Lasting power of attorney for health and welfare or court-appointed deputy (or equivalent) |
|
0 … * |
prsb03-dataelement-10425 link |
|
Details of the person's LPA record or equivalent |
|
|
0 … 1 |
prsb03-dataelement-13630 link |
|
The date the LPA was recordedDate and time |
|
|
0 … 1 |
prsb03-dataelement-13631 link |
|
The location where the LPA was given |
|
|
0 … 1 |
prsb03-dataelement-13632 link |
|
The coded value for locationNHS data dictionary : - Organisation code
|
|
|
0 … 1 |
prsb03-dataelement-13633 link |
|
Free text field to be used if no code is availableFree text |
|
|
|
Lasting power of attorney for health and welfare or court appointed deputy (or equivalent) |
|
0 … 1 |
prsb03-dataelement-13634 link |
|
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.
|
|
|
0 … 1 |
prsb03-dataelement-13636 link |
|
The coded value for the LPASNOMED CT: - ^999001951000000107 |Personal welfare lasting power of attorney findings
simple reference set (foundation metadata concept)|
|
|
|
0 … 1 |
prsb03-dataelement-13776 link |
|
The location of the LPA informationFree text or URL |
|
|
0 … 1 |
prsb03-dataelement-13635 link |
|
The names of any appointed people or deputiesFree text |
|
|
0 … 1 |
prsb03-dataelement-13637 link |
|
The contact details of the LPANHS data dictionary:- UK telephone number
|
|
|
0 … 1 |
prsb03-dataelement-13638 link |
|
The professional who took the details of the LPA or equivalent |
|
|
0 … 1 |
prsb03-dataelement-13639 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-13640 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
|
0 … 1 |
prsb03-dataelement-13641 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-13642 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-13643 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-13644 link |
|
The name of the organisation the professional works for. |
|
|
0 … 1 |
prsb03-dataelement-13645 link |
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
|
0 … 1 |
prsb03-dataelement-13646 link |
|
Details of the person who took the LPA. |
|
|
0 … 1 |
prsb03-dataelement-13647 link |
|
The name of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-13648 link |
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
|
0 … 1 |
prsb03-dataelement-13649 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-13650 link |
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-13651 link |
|
The organisation the person completing the record works for.
NHS data dictionary : -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-13652 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-13653 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-13654 link |
|
Contact details of the person completing the record.
NHS data dictionary : - UK telephone number
|
|
|
Deprivation of Liberty Safeguards or equivalent |
|
0 … * |
prsb03-dataelement-10426 link |
|
Details of the person's Deprivation of Liberty Safeguards (DoLS) or equivalent |
|
|
0 … 1 |
prsb03-dataelement-13068 link |
|
The date the application was madeDate and time |
|
|
0 … 1 |
prsb03-dataelement-13069 link |
|
The status of the DOLs application.Free text : - Requested or authorised |
|
|
|
Deprivation of liberty safeguards or equivalent |
|
0 … 1 |
prsb03-dataelement-13626 link |
|
Record of Deprivation of Liberty Safeguards (DoLS) or equivalent, including the reason
for this.Free text
|
|
|
|
Start date of authorisation |
|
0 … 1 |
prsb03-dataelement-13071 link |
|
The date the DOLs was authorised.Data and time |
|
|
|
Planned or actual end date of authorisation |
|
0 … 1 |
prsb03-dataelement-13072 link |
|
The planned or actual end date of authorisation.Date and time |
|
|
0 … 1 |
prsb03-dataelement-13073 link |
|
The professional who applied for the DOLs. |
|
|
0 … 1 |
prsb03-dataelement-13074 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-13075 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
|
0 … 1 |
prsb03-dataelement-13076 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-13077 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-13078 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-13079 link |
|
The name of the organisation the professional works for. |
|
|
0 … 1 |
prsb03-dataelement-13080 link |
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
|
Mental health act or equivalent status |
|
0 … * |
prsb03-dataelement-10427 link |
|
Details of the persons mental health act record |
|
|
0 … 1 |
prsb03-dataelement-10920 link |
|
The date the person was detained.Date and time |
|
|
0 … 1 |
prsb03-dataelement-10921 link |
|
The date the person was no longer detained.Date and time |
|
|
0 … 1 |
prsb03-dataelement-11692 link |
|
The location where the decision to detain the person was made under the mental health
act.
|
|
|
|
Mental health act or equivalent status |
|
0 … 1 |
prsb03-dataelement-13627 link |
|
Record where a person diagnosed with a mental disorder is formally detained under
the Mental health act or equivalent, including the section number. If person subject
to Community Treatment Order or Conditional Discharge (or equivalent) record here.
|
|
|
0 … 1 |
prsb03-dataelement-13628 link |
|
The coded value for mental health actNHS data dictionary: - Mental health act legal status classification code
|
|
|
0 … 1 |
prsb03-dataelement-13629 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-13755 link |
|
If person subject to Community Treatment Order or Conditional Discharge (or equivalent)
record here.NHS data dictionary : - Community treatment order
|
|
|
0 … 1 |
prsb03-dataelement-11315 link |
|
The professional who made the decision to detain the person under the mental health
act.
|
|
|
0 … 1 |
prsb03-dataelement-11316 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11317 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
|
0 … 1 |
prsb03-dataelement-11318 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-11319 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-11320 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-11321 link |
|
The name of the organisation the professional works for. |
|
|
0 … 1 |
prsb03-dataelement-11322 link |
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
|
0 … 1 |
prsb03-dataelement-11323 link |
|
Details of the person completing the record. |
|
|
0 … 1 |
prsb03-dataelement-11324 link |
|
The name of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11325 link |
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
|
0 … 1 |
prsb03-dataelement-11326 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11327 link |
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-11328 link |
|
The organisation the person completing the record works for.
NHS data dictionary : -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-11329 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-11330 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-11331 link |
|
Contact details of the person completing the record.
NHS data dictionary : - UK telephone number
|
|
|
Advance decision to refuse treatment (ADRT) |
|
0 … 1 |
prsb03-dataelement-10428 link |
|
Details of the person's ADRT status. |
|
|
0 … 1 |
prsb03-dataelement-13479 link |
|
The date the ADRT was recorded.Date |
|
|
0 … 1 |
prsb03-dataelement-13480 link |
|
The location where the ADRT was recorded. |
|
|
0 … 1 |
prsb03-dataelement-13481 link |
|
The coded value of locationNHS data dictionary : - Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-13482 link |
|
Free text field to be used if no coded text available |
|
|
|
Advance decision to refuse treatment |
|
0 … 1 |
prsb03-dataelement-13502 link |
|
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.
|
|
|
0 … 1 |
prsb03-dataelement-13503 link |
|
The coded value for advance decision to refuse treatment.SNOMED CT:- ^999002181000000105 |Advance decision to refuse treatment preference findings
simple reference set (foundation metadata concept)|
|
|
|
0 … 1 |
prsb03-dataelement-13504 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-13484 link |
|
The professional who recorded the ADRT |
|
|
0 … 1 |
prsb03-dataelement-13485 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-13486 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
|
0 … 1 |
prsb03-dataelement-13487 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-13488 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-13489 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-13490 link |
|
The name of the organisation the professional works for. |
|
|
0 … 1 |
prsb03-dataelement-13491 link |
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
|
0 … 1 |
prsb03-dataelement-13492 link |
|
Details of the person who recorded the ADRT. |
|
|
0 … 1 |
prsb03-dataelement-13493 link |
|
The name of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-13494 link |
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
|
0 … 1 |
prsb03-dataelement-13495 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-13496 link |
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-13497 link |
|
The organisation the person completing the record works for.
NHS data dictionary : -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-13498 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-13499 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-13500 link |
|
Contact details of the person completing the record.
NHS data dictionary : - UK telephone number
|
|
Safeguarding |
|
0 … 1 |
prsb03-dataelement-271 link |
|
The safeguarding details of the person. |
|
|
Safeguarding concerns |
|
0 … 1 |
prsb03-dataelement-10821 link |
|
Details of safeguarding concerns |
|
|
0 … 1 |
prsb03-dataelement-13428 link |
|
Indicates whether or not the hospital considers that there are safeguarding issues
associated with the patient.Flag: No =N: Yes = Y
|
|
|
|
Safeguarding concerns date |
|
0 … 1 |
prsb03-dataelement-10172 link |
|
The date the safeguarding concerns were identified.Date and time |
|
|
|
Safeguarding concerns end date |
|
0 … 1 |
prsb03-dataelement-10766 link |
|
The date safeguarding concerns ended.Date and time |
|
|
0 … 1 |
prsb03-dataelement-10173 link |
|
The location where the safeguarding concerns were identified. |
|
|
0 … 1 |
prsb03-dataelement-13437 link |
|
The coded value of locationNHS data dictionary : - Organisation code
|
|
|
0 … 1 |
prsb03-dataelement-13438 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-10171 link |
|
Identified safeguarding concerns. |
|
|
0 … 1 |
prsb03-dataelement-13756 link |
|
The coded value for safeguarding concernsSNOMED CT : - ^999002381000000108 | Safeguarding issues simple reference set (foundation
metadata concept) |
|
|
|
0 … 1 |
prsb03-dataelement-13757 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-11358 link |
|
The professional who identified the safeguarding concerns. |
|
|
0 … 1 |
prsb03-dataelement-11359 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11360 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
|
0 … 1 |
prsb03-dataelement-11361 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-11362 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-11363 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-11364 link |
|
The name of the organisation the professional works for. |
|
|
0 … 1 |
prsb03-dataelement-11365 link |
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
|
0 … 1 |
prsb03-dataelement-11366 link |
|
Details of the person completing the record. |
|
|
0 … 1 |
prsb03-dataelement-11367 link |
|
The name of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11368 link |
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
|
0 … 1 |
prsb03-dataelement-11369 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11370 link |
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-11371 link |
|
The organisation the person completing the record works for.
NHS data dictionary : -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-11372 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-11373 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-11374 link |
|
Contact details of the person completing the record.
NHS data dictionary : - UK telephone number
|
|
|
0 … 1 |
prsb03-dataelement-10175 link |
|
Further details on safeguarding concerns.Free text |
|
Professional contacts |
|
0 … 1 |
prsb03-dataelement-452 link |
|
The details of the person’s professional contacts. |
|
|
Professional contacts record entry |
|
0 … * |
prsb03-dataelement-10767 link |
|
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.
|
|
|
0 … 1 |
prsb03-dataelement-10352 link |
|
The name of the professional with responsibility for the care of the person.Free text |
|
|
0 … 1 |
prsb03-dataelement-10353 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker, key worker, care home manager, care coordinator, LA
hospital liaison person, care home contact, hospital clinician, Independent Mental
Capacity Advocate (IMCA) etcFHIR value set : - SDSjobrole
|
|
|
0 … 1 |
prsb03-dataelement-12973 link |
|
A flag that identifies the personal contact is the key worker assigned to the person.Flag : - Yes or No |
|
|
0 … 1 |
prsb03-dataelement-10354 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary : - Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-10355 link |
|
The name of the team.Free text |
|
|
0 … 1 |
prsb03-dataelement-10356 link |
|
The name of the organisation. |
|
|
0 … 1 |
prsb03-dataelement-13564 link |
|
The coded value for locationNHS data dictionary : - Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-13565 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-10357 link |
|
Contact details of the professional (e.g. telephone number, email address etc.).Free text |
|
|
0 … 1 |
prsb03-dataelement-10358 link |
|
The start date of the professional relationship with the person.Date and time |
|
|
0 … 1 |
prsb03-dataelement-10359 link |
|
The end date of the professional relationship with the person.Date and time |
|
Personal contacts |
|
0 … 1 |
prsb03-dataelement-445 link |
|
The details of the individual's personal contacts. |
|
|
Personal contacts record entry |
|
0 … * |
prsb03-dataelement-10768 link |
|
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.
|
|
|
0 … 1 |
prsb03-dataelement-10345 link |
|
The name of the personal contact.Free text |
|
|
0 … 1 |
prsb03-dataelement-10346 link |
|
The relationship the personal contact has to the person, e.g. father, grandmother,
family friend etc.FHIR value set : - Related person
|
|
|
0 … 1 |
prsb03-dataelement-12968 link |
|
Additional roles the person performs on behalf of the other (e.g. Carer, Next of Kin,
Emergency Contact, Dependent, etc.)Free text
|
|
|
0 … 1 |
prsb03-dataelement-10347 link |
|
Flag to indicate whether the personal contact has parental responsibilityFlag ; - Yes or No |
|
|
0 … 1 |
prsb03-dataelement-10348 link |
|
Status identifying whether the personal contact is a member of the same householdFlag : - Yes or No |
|
|
0 … 1 |
prsb03-dataelement-10350 link |
|
Contact details of the personal contact (e.g. telephone number, email address etc.)Free Text |
|
|
0 … 1 |
prsb03-dataelement-10937 link |
|
Notes on the significance of the personal contact to the person.Free text |
|
Participation in research |
|
0 … 1 |
prsb03-dataelement-168 link |
|
Participation in research |
|
|
Participation in research record entry |
|
0 … * |
prsb03-dataelement-10646 link |
|
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.
|
|
|
0 … 1 |
prsb03-dataelement-10068 link |
|
Name and details of the research study/trial and/or drug/interventionFree text or URL |
|
|
0 … 1 |
prsb03-dataelement-10739 link |
|
Identification code of research studyNHS data dictionary :- Clinical trial identifier
|
|
Referral details |
|
0 … 1 |
prsb03-dataelement-105 link |
|
The details of the referral. |
|
|
Referral details record entry |
|
0 … * |
prsb03-dataelement-10917 link |
|
This is the referral details record entry. There may be 0 to many record entries under
a section. Each record entry is made up of a number of elements or data items.
|
|
|
0 … 1 |
prsb03-dataelement-10006 link |
|
The date of referralDate and time |
|
|
0 … 1 |
prsb03-dataelement-10005 link |
|
The details of the referrer that is making the referral or the transfer.
This could be the person, GP surgery, department, specialty, sub-specialty, educational
institution, mental health team, care home etc.
|
|
|
0 … 1 |
prsb03-dataelement-10971 link |
|
The name of the referrer.Free text |
|
|
0 … 1 |
prsb03-dataelement-10972 link |
|
Role of the referrer.FHIR value set : - sdsjobrole
|
|
|
0 … 1 |
prsb03-dataelement-10973 link |
|
The grade of the referrer.Free text |
|
|
0 … 1 |
prsb03-dataelement-12409 link |
|
The team or department of the referrer.Free text |
|
|
0 … 1 |
prsb03-dataelement-12410 link |
|
The specialty of the referrer.NHS data dictionary - Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-12411 link |
|
The service of the referrer. |
|
|
0 … 1 |
prsb03-dataelement-13397 link |
|
The coded value for serviceSNOMED CT: - 1127531000000102 |Services simple reference set (foundation metadata
concept)|
|
|
|
0 … 1 |
prsb03-dataelement-13398 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-10974 link |
|
The organisation of the referrer. |
|
|
0 … 1 |
prsb03-dataelement-13399 link |
|
The coded value for organisation codeNHS data dictionary : - Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-13400 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-10975 link |
|
The contact details of the referrer.Free text |
|
Contacts with professionals |
|
1 … 1 Mandatory |
prsb03-dataelement-169 link |
|
The details of the person’s contact with a professional. |
|
|
Contacts with professionals record entry |
|
0 … * |
prsb03-dataelement-10718 link |
|
This is a contacts record entry. There may be 0 to many record entries under a section.
Each record entry is made up of a number of elements or data items.
|
|
|
1 … 1 Mandatory |
prsb03-dataelement-10069 link |
|
Date and time of the contact.Date and time. |
|
|
1 … 1 Mandatory |
prsb03-dataelement-10077 link |
|
The professional that saw the person. |
|
|
1 … 1 Mandatory |
prsb03-dataelement-10072 link |
|
The name and role of the professional that had overall responsibility for the person
e.g. consultant, nurse consultant, midwife, allied health professional (may not have
actually seen the person).
|
|
|
0 … * |
prsb03-dataelement-10070 link |
|
Type of contact e.g. GP consultation, outpatient attendanceFree text |
|
|
0 … 1 |
prsb03-dataelement-10071 link |
|
Consultation method used e.g. face to face, telephoneNHS data dictionary - Consultation medium
|
|
|
0 … 1 |
prsb03-dataelement-10073 link |
|
The specialty e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-10074 link |
|
The service that was provided.SNOMED CT :- 1127531000000102 |Services simple reference set (foundation metadata
concept)|
|
|
|
0 … * |
prsb03-dataelement-10078 link |
|
The name, role of the additional individuals or team members including consultant(s),
nurse consultant(s), allied health professional(s), social worker(s)
|
|
|
0 … 1 |
prsb03-dataelement-10080 link |
|
This records the outcome of the contact.
NHS data dictionary :- Attended or did not attend code
|
|
|
|
Person accompanying patient |
|
0 … 1 |
prsb03-dataelement-10079 link |
|
Identify, where clinically relevant, others accompanying the patient, e.g. parent,
relative, friend. Includes: Name, Relationship, role (e.g. informal carer).NHS data dictionary : - Person full name
|
|
Relevant clinical risk factors |
|
0 … 1 |
prsb03-dataelement-203 link |
|
Relevant clinical risk factors |
|
|
Relevant clinical risk factor record entry |
|
0 … * |
prsb03-dataelement-10650 link |
|
This is a Relevant clinical risk factor 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.
|
|
|
|
Relevant clinical risk factor |
|
0 … * |
prsb03-dataelement-10103 link |
|
Factors that have been shown to be associated with the development of a medical condition
being considered as a diagnosis/differential diagnosis. E.g. being overweight, smoker,
no use of sun screen, enzyme deficiency.Free text
|
|
|
0 … * |
prsb03-dataelement-10107 link |
|
Specific risk assessments required/undertaken.Coded (SNOMED CT) or text |
|
|
0 … 1 |
prsb03-dataelement-10108 link |
|
Action taken to reduce the clinical risk and date actions.Free text |
|
Problem list |
|
1 … 1 |
prsb03-dataelement-10927 link |
|
A summary of the problems that require investigation or treatment. |
|
|
Problem list record entry |
|
0 … * |
prsb03-dataelement-10928 link |
|
This is a problem list record entry.
There may be 0 to many record entries under problem list.
Each record entry is made up of a number of elements or data items.
|
|
|
0 … 1 |
prsb03-dataelement-10929 link |
|
The date the problem was identified.Date and time |
|
|
0 … 1 |
prsb03-dataelement-12133 link |
|
The professional who identified the problem. |
|
|
0 … 1 |
prsb03-dataelement-12134 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-12135 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
|
0 … 1 |
prsb03-dataelement-12136 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-12137 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-12138 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-12139 link |
|
The name of the organisation the professional works for. |
|
|
0 … 1 |
prsb03-dataelement-12140 link |
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
|
0 … 1 |
prsb03-dataelement-10931 link |
|
The location the problem was identified. |
|
|
0 … 1 |
prsb03-dataelement-13242 link |
|
The coded value for location.NHS data dictionary : - Organisation data service code
|
|
|
0 … 1 |
prsb03-dataelement-13243 link |
|
Free text field to be used if no code is availableFree text |
|
|
1 … 1 |
prsb03-dataelement-10932 link |
|
A condition which needs addressing and so is important for every professional to know
about when seeing the person.
Problems may include diagnoses, symptoms, disabilities and social or behavioural issues
|
|
|
0 … 1 |
prsb03-dataelement-13244 link |
|
The coded value for the problem list.SNOMED CT : - ^1127581000000103 |Health issues simple reference set|
|
|
|
0 … 1 |
prsb03-dataelement-13245 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-10933 link |
|
A date or estimated date that the problem beganDate and time |
|
|
0 … 1 |
prsb03-dataelement-10934 link |
|
The date or estimated date the problem was resolved.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-10935 link |
|
The stage of the disease where relevant.Free text |
|
|
0 … 1 |
prsb03-dataelement-12141 link |
|
Details of the person completing the record. |
|
|
0 … 1 |
prsb03-dataelement-12142 link |
|
The name of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-12143 link |
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
|
0 … 1 |
prsb03-dataelement-12144 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-12145 link |
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-12146 link |
|
The organisation the person completing the record works for.
NHS data dictionary : -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-12147 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-12148 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-12149 link |
|
Contact details of the person completing the record.
NHS data dictionary : - UK telephone number
|
|
|
0 … * |
prsb03-dataelement-10936 link |
|
Supporting text may be given covering the problem.Free text |
|
Procedures and therapies |
|
0 … 1 |
prsb03-dataelement-238 link |
|
The details of any procedures performed. Includes both psychological and medical therapies
and procedures (e.g. cognitive behaviour therapy, hip replacement)
|
|
|
Procedure record entry |
|
0 … * |
prsb03-dataelement-10652 link |
|
This is a procedure record entry. There may be 0 to many record entries under a section.
Each record entry is made up of a number of elements or data items.
|
|
|
0 … 1 |
prsb03-dataelement-10138 link |
|
The date the procedure was performed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-13246 link |
|
The location where the procedure was undertaken. |
|
|
0 … 1 |
prsb03-dataelement-13247 link |
|
The coded value for location.NHS data dictionary : - Organisation data service code
|
|
|
0 … 1 |
prsb03-dataelement-13248 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-12150 link |
|
The professional who performed the procedure. |
|
|
0 … 1 |
prsb03-dataelement-12151 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-12152 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
|
0 … 1 |
prsb03-dataelement-12153 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-12154 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-12155 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-12156 link |
|
The name of the organisation the professional works for. |
|
|
0 … 1 |
prsb03-dataelement-12157 link |
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
|
1 … 1 |
prsb03-dataelement-10141 link |
|
The therapeutic or diagnostic procedure performed. Includes both psychological and
medical therapies and procedures (e.g. cognitive
behaviour therapy, or follow-up interventions as a result of physical health
checks). Complementary or alternative procedures and therapies should be recorded
here.
|
|
|
0 … 1 |
prsb03-dataelement-13249 link |
|
The procedure code.SNOMED CT : - <<71388002 |Procedure| OR <<129125009 |Procedure with explicit context| |
|
|
0 … 1 |
prsb03-dataelement-13250 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-10142 link |
|
The body site of the procedure |
|
|
0 … 1 |
prsb03-dataelement-13251 link |
|
The coded value of the anatomical site.SNOMED CT :- <123037004 |Body structure (body structure)| |
|
|
0 … 1 |
prsb03-dataelement-13252 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-10143 link |
|
Laterality of the procedure |
|
|
0 … 1 |
prsb03-dataelement-13253 link |
|
The coded value for laterality.SNOMED CT:- <182353008 |Side (qualifier value)| |
|
|
0 … 1 |
prsb03-dataelement-13254 link |
|
Free text field to be used if no code is availableFree text |
|
|
|
Complications related to procedure |
|
0 … 1 |
prsb03-dataelement-10144 link |
|
Details of any intra-operative complications encountered during the procedure, arising
during the person’s stay in the recovery unit or directly attributable to the procedure.
|
|
|
0 … 1 |
prsb03-dataelement-13255 link |
|
The coded value for complications relating to procedure.SNOMED CT : - <404684003 |Clinical finding (finding)|
|
|
|
0 … 1 |
prsb03-dataelement-13256 link |
|
Free text field to be used if no code is availableFree text |
|
|
|
Specific anesthesia issues |
|
0 … 1 |
prsb03-dataelement-10145 link |
|
Details of any adverse reaction to any anesthetic agents including local anesthesia.
Problematic intubation, transfusion reaction, etc.
|
|
|
0 … 1 |
prsb03-dataelement-13257 link |
|
The coded value for specific anesthesia issues.SNOMED CT |
|
|
0 … 1 |
prsb03-dataelement-13258 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-12158 link |
|
Details of the person completing the record. |
|
|
0 … 1 |
prsb03-dataelement-12159 link |
|
The name of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-12160 link |
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
|
0 … 1 |
prsb03-dataelement-12161 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-12162 link |
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-12163 link |
|
The organisation the person completing the record works for.
NHS data dictionary : -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-12164 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-12165 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-12166 link |
|
Contact details of the person completing the record.
NHS data dictionary : - UK telephone number
|
|
|
0 … 1 |
prsb03-dataelement-10146 link |
|
Any further textual comment to clarify such as statement that information is partial
or incomplete. Also indicate the outcome of the procedure.Free text
|
|
History |
|
0 … 1 |
prsb03-dataelement-226 link |
|
Information relating to the evolution of each presenting complaint, and the patient's
relevant health history.
|
|
|
Patient’s reason for referral |
|
0 … 1 |
prsb03-dataelement-10126 link |
|
Patient stated reason for referral. This may include any discussions that took place,
the level of shared decision making involved, information about patient’s source of
advice. This may be expressed on behalf of the patient, e.g. by parent or carer.
|
|
|
0 … 1 |
prsb03-dataelement-14265 link |
|
The coded value for patients reason for referralSNOMED CT :- ^1127581000000103 |Health issues simple reference set|
|
|
|
0 … 1 |
prsb03-dataelement-14266 link |
|
Free text field to be used if no code is availableFree text |
|
|
Presenting complaint or issue |
|
0 … * |
prsb03-dataelement-14274 link |
|
The health problem or issue experienced by the person resulting in their attendance.
This may include disease state, medical condition, response and reactions to therapies.
e.g., blackout, dizziness, chest pain, follow up from admission, falls, a specific
procedure, investigation or treatment.
|
|
|
0 … * |
prsb03-dataelement-14275 link |
|
The coded value for presenting complaint or issueSNOMED CT : - ^1127581000000103 |Health issues simple reference set|
|
|
|
0 … * |
prsb03-dataelement-14276 link |
|
Free text |
|
|
History of each presenting complaint or issue |
|
0 … * |
prsb03-dataelement-10128 link |
|
Information directly related to the development and characteristics of each presenting
complaint (e.g. including travel history). Including if the information is given by
the patient or their carer. This textual description may be provided by the referral
document or during the consultationFree text
|
|
|
History since last contact |
|
0 … 1 |
prsb03-dataelement-10129 link |
|
History since last attendance, discharge from hospital, etc. To include adherence
to treatment plan, where appropriateFree text
|
|
|
Relevant past medical, surgical and mental health history |
|
0 … * |
prsb03-dataelement-10130 link |
|
The record of the person’s significant medical, surgical and mental health history.
Including relevant previous diagnoses, problems and issues, procedures, investigations,
specific anesthesia issues, etc. (will include dental and obstetric history)
A list of the person's relevant past medical, surgical and mental health history recorded
in free text or coded form or Information relating to past medical, surgical and mental
health history may be provided by the referral document or during the consultation.
|
|
|
0 … * |
prsb03-dataelement-13787 link |
|
The coded value relevant past medical, surgical and mental health historySNOMED CT : - ^1127581000000103 |Health issues simple reference set|
|
|
|
0 … * |
prsb03-dataelement-13788 link |
|
Free text field to be used if no code is availableFree text |
|
|
Clinical Review of Systems |
|
0 … 1 |
prsb03-dataelement-14277 link |
|
Information gathered on symptoms related to physiological systems. |
|
|
|
Clinical review of systems |
|
0 … 1 |
prsb03-dataelement-14278 link |
|
The clinical review of systems. This is the record of the review of systems as volunteered
by the patient or their representative or carer. The record of clinical information
gathered in responses to questions to the patient about specific symptoms from various
physiological systems, including food intake (increasing/decreasing) weight change,
swallowing difficulties etc. SNOMED CT: - 415300000 |Review of systems (procedure)|
|
|
Clinical Summary |
|
1 … 1 Mandatory |
prsb03-dataelement-247 link |
|
Clinical Summary |
|
|
Clinical summary |
|
1 … 1 Mandatory |
prsb03-dataelement-10147 link |
|
Summary of the encounter. Where possible, very brief. This may include interpretation
of findings and results; differential diagnoses, opinion and specific action(s). Planned
actions will be recorded under ‘plan’.Free text
|
|
Social context |
|
0 … 1 |
prsb03-dataelement-136 link |
|
The social setting in which the person lives, such as their household, occupational
history, and lifestyle factors.
|
|
|
Household composition |
|
0 … 1 |
prsb03-dataelement-10036 link |
|
Details of the person's household composition. |
|
|
0 … 1 |
prsb03-dataelement-11770 link |
|
The date when the household composition was taken.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-13271 link |
|
The location where the household composition was taken. |
|
|
0 … 1 |
prsb03-dataelement-13272 link |
|
The coded value for location.NHS data dictionary : - Organisation data service code
|
|
|
0 … 1 |
prsb03-dataelement-13273 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-13261 link |
|
Description of the household composition e.g. lives alone, lives with family, lives
with partner, shared accommodation etc.
|
|
|
0 … 1 |
prsb03-dataelement-13262 link |
|
The coded value of household compositionSNOMED CT: - 1027891000000106 | Household composition findings simple reference set
(foundation metadata concept) |
|
|
|
0 … 1 |
prsb03-dataelement-13263 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-11648 link |
|
The professional who took the household composition. |
|
|
0 … 1 |
prsb03-dataelement-11649 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11650 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
|
0 … 1 |
prsb03-dataelement-11651 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-11652 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-11653 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-11654 link |
|
The name of the organisation the professional works for. |
|
|
0 … 1 |
prsb03-dataelement-11655 link |
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
|
0 … 1 |
prsb03-dataelement-11521 link |
|
Details of the person completing the record. |
|
|
0 … 1 |
prsb03-dataelement-11522 link |
|
The name of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11523 link |
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
|
0 … 1 |
prsb03-dataelement-11524 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11525 link |
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-11526 link |
|
The organisation the person completing the record works for.
NHS data dictionary : -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-11527 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-11528 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-11529 link |
|
Contact details of the person completing the record.
NHS data dictionary : - UK telephone number
|
|
|
Occupational history |
|
0 … 1 |
prsb03-dataelement-10037 link |
|
The current and/or previous occupation(s) of the person. |
|
|
0 … 1 |
prsb03-dataelement-11772 link |
|
The date when the occupational history was taken.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-11773 link |
|
The location where the occupational history was taken. |
|
|
0 … 1 |
prsb03-dataelement-13274 link |
|
The coded value for the location.NHS Data dictionary : - Organisation data service code
|
|
|
0 … 1 |
prsb03-dataelement-13275 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-13264 link |
|
The current and/or previous occupation(s) of the person. |
|
|
0 … 1 |
prsb03-dataelement-13265 link |
|
The coded value for occupational historySNOMED CT : - ^999001571000000109 | Occupation simple reference set (foundation metadata
concept)
|
|
|
0 … 1 |
prsb03-dataelement-13266 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-11656 link |
|
The professional who took the occupational history. |
|
|
0 … 1 |
prsb03-dataelement-11657 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11658 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
|
0 … 1 |
prsb03-dataelement-11659 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-11660 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-11661 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-11662 link |
|
The name of the organisation the professional works for. |
|
|
0 … 1 |
prsb03-dataelement-11663 link |
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
|
0 … 1 |
prsb03-dataelement-11530 link |
|
Details of the person completing the record. |
|
|
0 … 1 |
prsb03-dataelement-11531 link |
|
The name of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11532 link |
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
|
0 … 1 |
prsb03-dataelement-11533 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11534 link |
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-11535 link |
|
The organisation the person completing the record works for.
NHS data dictionary : -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-11536 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-11537 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-11538 link |
|
Contact details of the person completing the record.
NHS data dictionary : - UK telephone number
|
|
|
Educational history |
|
0 … 1 |
prsb03-dataelement-10038 link |
|
Details of the person's educational history. |
|
|
0 … 1 |
prsb03-dataelement-11774 link |
|
The date when the educational history was taken.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-11775 link |
|
The location where the education history was taken. |
|
|
0 … 1 |
prsb03-dataelement-13276 link |
|
The coded value for location.NHS Data dictionary : - Organisation data service code
|
|
|
0 … 1 |
prsb03-dataelement-13277 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-13840 link |
|
The current and/or previous relevant educational history of the person.Free text |
|
|
0 … 1 |
prsb03-dataelement-11776 link |
|
The professional who took the educational history. |
|
|
0 … 1 |
prsb03-dataelement-11777 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11778 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
|
0 … 1 |
prsb03-dataelement-11779 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-11780 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-11781 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-11782 link |
|
The name of the organisation the professional works for. |
|
|
0 … 1 |
prsb03-dataelement-11783 link |
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
|
0 … 1 |
prsb03-dataelement-11539 link |
|
Details of the person completing the record. |
|
|
0 … 1 |
prsb03-dataelement-11540 link |
|
The name of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11541 link |
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
|
0 … 1 |
prsb03-dataelement-11542 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11543 link |
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-11544 link |
|
The organisation the person completing the record works for.
NHS data dictionary : -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-11545 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-11546 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-11547 link |
|
Contact details of the person completing the record.
NHS data dictionary : - UK telephone number
|
|
|
Lifestyle choices |
|
0 … 1 |
prsb03-dataelement-10039 link |
|
The lifestyle choices made by the person which are pertinent to his or her health
and well-being, e.g. physical activity level, pets, hobbies and sexual habits
|
|
|
0 … 1 |
prsb03-dataelement-11784 link |
|
The date when the lifestyle choices were taken.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-11785 link |
|
The location where the lifestyle choices were taken. |
|
|
0 … 1 |
prsb03-dataelement-13278 link |
|
The coded value for location.NHS Data dictionary : - Organisation data service code
|
|
|
0 … 1 |
prsb03-dataelement-13279 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-13841 link |
|
The lifestyle choices made by the person which are pertinent to his or her health
and well-being, e.g. physical activity level, pets, hobbies and sexual preferences.Free text
|
|
|
0 … 1 |
prsb03-dataelement-11786 link |
|
The professional who took the lifestyle choices. |
|
|
0 … 1 |
prsb03-dataelement-11787 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11788 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
|
0 … 1 |
prsb03-dataelement-11789 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-11790 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-11791 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-11792 link |
|
The name of the organisation the professional works for. |
|
|
0 … 1 |
prsb03-dataelement-11793 link |
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
|
0 … 1 |
prsb03-dataelement-11548 link |
|
Details of the person completing the record. |
|
|
0 … 1 |
prsb03-dataelement-11549 link |
|
The name of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11550 link |
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
|
0 … 1 |
prsb03-dataelement-11551 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11552 link |
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-11553 link |
|
The organisation the person completing the record works for.
NHS data dictionary : -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-11554 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-11555 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-11556 link |
|
Contact details of the person completing the record.
NHS data dictionary : - UK telephone number
|
|
|
Smoking status |
|
0 … 1 |
prsb03-dataelement-10040 link |
|
Details of the person's smoking status. |
|
|
0 … 1 |
prsb03-dataelement-11794 link |
|
The date when the smoking status was taken.Date and time |
|
|
0 … 1 |
prsb03-dataelement-11795 link |
|
The location where the smoking status was taken. |
|
|
0 … 1 |
prsb03-dataelement-13281 link |
|
The coded value for locationNHS data dictionary : - Organisation data service code
|
|
|
0 … 1 |
prsb03-dataelement-13282 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-13283 link |
|
Record of any smoking use by the person.
|
|
|
0 … 1 |
prsb03-dataelement-13284 link |
|
The smoking status of the person.SNOMED CT:- ^999000891000000102 |Smoking simple reference set (foundation metadata
concept)|
|
|
|
0 … 1 |
prsb03-dataelement-13285 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-13286 link |
|
Further details recorded about the smoking status of the personFree text |
|
|
0 … 1 |
prsb03-dataelement-13287 link |
|
The date the person stopped smoking (if known) |
|
|
0 … 1 |
prsb03-dataelement-13288 link |
|
The coded value for date stopped smoking.SNOMED CT:- 160625004 |Date ceased smoking (observable entity)| |
|
|
0 … 1 |
prsb03-dataelement-13289 link |
|
The date the person stopped smoking.Date and time |
|
|
0 … 1 |
prsb03-dataelement-11796 link |
|
The professional who took the smoking status. |
|
|
0 … 1 |
prsb03-dataelement-11797 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11798 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
|
0 … 1 |
prsb03-dataelement-11799 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-11800 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-11801 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-11802 link |
|
The name of the organisation the professional works for. |
|
|
0 … 1 |
prsb03-dataelement-11803 link |
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
|
0 … 1 |
prsb03-dataelement-11557 link |
|
Details of the person completing the record. |
|
|
0 … 1 |
prsb03-dataelement-11558 link |
|
The name of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11559 link |
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
|
0 … 1 |
prsb03-dataelement-11560 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11561 link |
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-11562 link |
|
The organisation the person completing the record works for.
NHS data dictionary : -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-11563 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-11564 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-11565 link |
|
Contact details of the person completing the record.
NHS data dictionary : - UK telephone number
|
|
|
Alcohol intake |
|
0 … 1 |
prsb03-dataelement-10041 link |
|
Details of the person's alcohol intake |
|
|
0 … 1 |
prsb03-dataelement-11804 link |
|
The date when the alcohol intake was noted.Date and time |
|
|
0 … 1 |
prsb03-dataelement-11805 link |
|
The location where the alcohol intake was noted. |
|
|
0 … 1 |
prsb03-dataelement-13332 link |
|
The coded value for location.NHS Data dictionary : - Organisation data service code
|
|
|
0 … 1 |
prsb03-dataelement-13333 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-13290 link |
|
Latest or current alcohol consumption. |
|
|
0 … 1 |
prsb03-dataelement-13291 link |
|
The coded value of the person alcohol intakeSNOMED CT :- 219006 |Current drinker of alcohol (finding)| OR 105542008 |Current non-drinker
of alcohol (finding)| OR 228274009 |Lifetime non-drinker (finding)| OR 1104551000000109
|Declined to provide information about alcohol use (situation)| OR 371434005 |History
of alcohol abuse (situation)|
|
|
|
0 … 1 |
prsb03-dataelement-13292 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-11806 link |
|
The professional who noted the alcohol intake. |
|
|
0 … 1 |
prsb03-dataelement-11807 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11808 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
|
0 … 1 |
prsb03-dataelement-11809 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-11810 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-11811 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-11812 link |
|
The name of the organisation the professional works for. |
|
|
0 … 1 |
prsb03-dataelement-11813 link |
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
|
0 … 1 |
prsb03-dataelement-11566 link |
|
Details of the person completing the record. |
|
|
0 … 1 |
prsb03-dataelement-11567 link |
|
The name of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11568 link |
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
|
0 … 1 |
prsb03-dataelement-11569 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11570 link |
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-11571 link |
|
The organisation the person completing the record works for.
NHS data dictionary : -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-11572 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-11573 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-11574 link |
|
Contact details of the person completing the record.
NHS data dictionary : - UK telephone number
|
|
|
Drug/substance use |
|
0 … 1 |
prsb03-dataelement-10042 link |
|
Details of the person's drug and substance use. |
|
|
0 … 1 |
prsb03-dataelement-11814 link |
|
The date when the drug/substance use was noted.Date and time |
|
|
0 … 1 |
prsb03-dataelement-11815 link |
|
The location where the drug/substance use was noted. |
|
|
0 … 1 |
prsb03-dataelement-13334 link |
|
The coded value for location.NHS Data dictionary : - Organisation data service code
|
|
|
0 … 1 |
prsb03-dataelement-13335 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-13336 link |
|
Latest or current drug/substance use. |
|
|
0 … 1 |
prsb03-dataelement-13337 link |
|
The coded value for drug and substance misuse.SNOMED CT:- 361055000 |Misuses drugs (finding)| OR 371422002 |History of substance
abuse (situation)| OR 228368007 |Has never misused drugs (situation)| OR 783241000000102
|Declined to give substance misuse history (finding)|
|
|
|
0 … 1 |
prsb03-dataelement-13338 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-11816 link |
|
The professional who noted the drug/substance use. |
|
|
0 … 1 |
prsb03-dataelement-11817 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11818 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
|
0 … 1 |
prsb03-dataelement-11819 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-11820 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-11821 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-11822 link |
|
The name of the organisation the professional works for. |
|
|
0 … 1 |
prsb03-dataelement-11823 link |
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
|
0 … 1 |
prsb03-dataelement-11575 link |
|
Details of the person completing the record. |
|
|
0 … 1 |
prsb03-dataelement-11576 link |
|
The name of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11577 link |
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
|
0 … 1 |
prsb03-dataelement-11578 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11579 link |
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-11580 link |
|
The organisation the person completing the record works for.
NHS data dictionary : -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-11581 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-11582 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-11583 link |
|
Contact details of the person completing the record.
NHS data dictionary : - UK telephone number
|
|
|
Social circumstances |
|
0 … 1 |
prsb03-dataelement-10043 link |
|
Details of the persons social circumstances |
|
|
0 … 1 |
prsb03-dataelement-11824 link |
|
The date when the social circumstances were taken.Date and time |
|
|
0 … 1 |
prsb03-dataelement-11825 link |
|
The location where the social circumstances were taken. |
|
|
0 … 1 |
prsb03-dataelement-13339 link |
|
The coded value for the location |
|
|
0 … 1 |
prsb03-dataelement-13340 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-13341 link |
|
A person’s social background, network and personal circumstances, e.g. housing. This
should include whether the person is a carer.Free text
|
|
|
0 … 1 |
prsb03-dataelement-11826 link |
|
The professional who took the social circumstances. |
|
|
0 … 1 |
prsb03-dataelement-11827 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11828 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
|
0 … 1 |
prsb03-dataelement-11829 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-11830 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-11831 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-11832 link |
|
The name of the organisation the professional works for. |
|
|
0 … 1 |
prsb03-dataelement-11833 link |
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
|
0 … 1 |
prsb03-dataelement-11584 link |
|
Details of the person completing the record. |
|
|
0 … 1 |
prsb03-dataelement-11585 link |
|
The name of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11586 link |
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
|
0 … 1 |
prsb03-dataelement-11587 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11588 link |
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-11589 link |
|
The organisation the person completing the record works for.
NHS data dictionary : -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-11590 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-11591 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-11592 link |
|
Contact details of the person completing the record.
NHS data dictionary : - UK telephone number
|
|
Services and care |
|
0 … 1 |
prsb03-dataelement-10044 link |
|
The services and care provided for the person. |
|
|
Services and care record entry |
|
0 … * |
prsb03-dataelement-12421 link |
|
This is a services and care record entry. There may be 0 to many record entries under
a section. Each record entry is made up of a number of elements or data items.
|
|
|
0 … 1 |
prsb03-dataelement-12965 link |
|
Name of specific type of package being provided (e.g. Reablement, Home Based Care
XYZ, etc)Free text
|
|
|
0 … 1 |
prsb03-dataelement-12966 link |
|
Higher level categorisation of package type, e.g. Adults Home SupportFree text |
|
|
0 … 1 |
prsb03-dataelement-11834 link |
|
The date service started to be provided.Date and time |
|
|
0 … 1 |
prsb03-dataelement-12420 link |
|
The date the service is planned to be ended or the actual end date.Date and time |
|
|
0 … 1 |
prsb03-dataelement-11835 link |
|
The name of the local authority providing the care package. |
|
|
0 … 1 |
prsb03-dataelement-13566 link |
|
The coded value for local authorityNHS data dictionary: - Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-13567 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-13067 link |
|
A reference to the funding source and any conditions or limitations associated. |
|
|
0 … 1 |
prsb03-dataelement-11836 link |
|
The professional providing the service.Free text |
|
|
0 … 1 |
prsb03-dataelement-11837 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11838 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
|
0 … 1 |
prsb03-dataelement-11839 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-11840 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-11841 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-11842 link |
|
The name of the organisation the professional works for. |
|
|
0 … 1 |
prsb03-dataelement-11843 link |
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
|
0 … 1 |
prsb03-dataelement-11593 link |
|
Details of the person completing the record. |
|
|
0 … 1 |
prsb03-dataelement-11594 link |
|
The name of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11595 link |
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
|
0 … 1 |
prsb03-dataelement-11596 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11597 link |
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-11598 link |
|
The organisation the person completing the record works for.
NHS data dictionary : -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-11599 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-11600 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-11601 link |
|
Contact details of the person completing the record.
NHS data dictionary : - UK telephone number
|
|
Family history |
|
0 … 1 |
prsb03-dataelement-251 link |
|
Family history |
|
|
Family history record entry |
|
0 … * |
prsb03-dataelement-10653 link |
|
This is a family history record entry. There may be 0 to many record entry/entries
under a section. Each record entry is made up of a number of elements or data items.
|
|
|
0 … 1 |
prsb03-dataelement-10153 link |
|
The date the family history was taken.Date and time |
|
|
0 … 1 |
prsb03-dataelement-10851 link |
|
The location where the family history was taken. |
|
|
0 … 1 |
prsb03-dataelement-13682 link |
|
The coded value for locationNHS data dictionary : - Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-13683 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-11640 link |
|
The professional who took the family history. |
|
|
0 … 1 |
prsb03-dataelement-11641 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11642 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
|
0 … 1 |
prsb03-dataelement-11643 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-11644 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-11645 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-11646 link |
|
The name of the organisation the professional works for. |
|
|
0 … 1 |
prsb03-dataelement-11647 link |
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
|
0 … 1 |
prsb03-dataelement-10155 link |
|
The relationship of the family member with the condition to the person. |
|
|
0 … 1 |
prsb03-dataelement-13676 link |
|
The coded value for relationship to personSNOMED CT: - <303071001 |Person in the family (person)|
|
|
|
0 … 1 |
prsb03-dataelement-13677 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-10151 link |
|
The record of relevant illness in family relations deemed to be significant to the
care or health of the person, including mental illness and suicide, genetic information
etc.
|
|
|
0 … 1 |
prsb03-dataelement-13678 link |
|
The coded value for family historySNOMED CT:- <404684003 |Clinical finding (finding)| OR <243796009 |Situation with
explicit context (situation)|
|
|
|
0 … 1 |
prsb03-dataelement-13679 link |
|
Free text field to be used if no coded text available |
|
|
0 … 1 |
prsb03-dataelement-11630 link |
|
Details of the person completing the record. |
|
|
0 … 1 |
prsb03-dataelement-11631 link |
|
The name of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11632 link |
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
|
0 … 1 |
prsb03-dataelement-11633 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11634 link |
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-11635 link |
|
The organisation the person completing the record works for.
NHS data dictionary : -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-11636 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-11637 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-11638 link |
|
Contact details of the person completing the record.
NHS data dictionary : - UK telephone number
|
|
|
0 … 1 |
prsb03-dataelement-10156 link |
|
Any further textual comment.Free text |
|
Investigation results |
|
0 … 1 |
prsb03-dataelement-257 link |
|
Investigation results |
|
|
Investigation results record entry |
|
0 … * |
prsb03-dataelement-10654 link |
|
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.
|
|
|
0 … 1 |
prsb03-dataelement-10157 link |
|
The date and time when the investigation was performedDate and time |
|
|
0 … 1 |
prsb03-dataelement-12099 link |
|
The professional who performed the investigation. |
|
|
0 … 1 |
prsb03-dataelement-12100 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-12101 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
|
0 … 1 |
prsb03-dataelement-12102 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-12103 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-12104 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-12105 link |
|
The name of the organisation the professional works for. |
|
|
0 … 1 |
prsb03-dataelement-12106 link |
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
|
0 … 1 |
prsb03-dataelement-10159 link |
|
The location where the investigation took place. |
|
|
0 … 1 |
prsb03-dataelement-13725 link |
|
The coded value for locationNHS data dictionary : Organisation data service |
|
|
0 … 1 |
prsb03-dataelement-13726 link |
|
Free text field to be used if no code is availableFree text |
|
|
1 … 1 |
prsb03-dataelement-10160 link |
|
The investigation performed. |
|
|
0 … 1 |
prsb03-dataelement-13525 link |
|
The coded value for investigationSNOMED CT: - <71388002 |Procedure (procedure)|
|
|
|
0 … 1 |
prsb03-dataelement-13526 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-10161 link |
|
For each investigation, the result of the investigation. This can include a report
which may have results for multiple tests.
|
|
|
0 … 1 |
prsb03-dataelement-13527 link |
|
The coded value for investigation resultsSNOMED CT:- <404684003 |Clinical finding (finding)| OR <243796009 |Situation with
explicit context (situation)|
|
|
|
0 … 1 |
prsb03-dataelement-13528 link |
|
Free text field to be used if no code is availableFree text |
|
|
|
Structured investigation result |
|
0 … 1 |
prsb03-dataelement-12415 link |
|
A structured set of information for each investigation result. |
|
|
0 … 1 |
prsb03-dataelement-12416 link |
|
The value of the investigation result.Numeric |
|
|
0 … 1 |
prsb03-dataelement-12417 link |
|
The units of the investigation result.UCUM code |
|
|
0 … 1 |
prsb03-dataelement-12418 link |
|
The reference range for the investigation result.Free text |
|
|
0 … 1 |
prsb03-dataelement-12419 link |
|
Indicator if the investigation is abnormal.Abnormal or Normal |
|
|
0 … 1 |
prsb03-dataelement-12107 link |
|
Details of the person completing the record. |
|
|
0 … 1 |
prsb03-dataelement-12108 link |
|
The name of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-12109 link |
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
|
0 … 1 |
prsb03-dataelement-12110 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-12111 link |
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-12112 link |
|
The organisation the person completing the record works for.
NHS data dictionary : -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-12113 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-12114 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-12115 link |
|
Contact details of the person completing the record.
NHS data dictionary : - UK telephone number
|
|
Examination findings |
|
0 … 1 |
prsb03-dataelement-557 link |
|
Examination findings |
|
|
Examination findings record entry |
|
0 … * |
prsb03-dataelement-10662 link |
|
This is a examination findings record entry. There may be 0 to many record entry/entries
under a section. Each record entry is made up of a number of elements or data items.
|
|
|
0 … 1 |
prsb03-dataelement-10462 link |
|
The date the examination was performed.Date and time |
|
|
0 … 1 |
prsb03-dataelement-12116 link |
|
The professional who performed the examiniation. |
|
|
0 … 1 |
prsb03-dataelement-12117 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-12118 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
|
0 … 1 |
prsb03-dataelement-12119 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-12120 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-12121 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-12122 link |
|
The name of the organisation the professional works for. |
|
|
0 … 1 |
prsb03-dataelement-12123 link |
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
|
0 … 1 |
prsb03-dataelement-10461 link |
|
The location where the examination was performed. |
|
|
0 … 1 |
prsb03-dataelement-13445 link |
|
The coded value for locationNHS data dictionary : - Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-13446 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-10458 link |
|
The record of findings from the examinations performed. |
|
|
0 … 1 |
prsb03-dataelement-13443 link |
|
The coded value for examination findingsSNOMED CT : - ^1127601000000107 |Healthcare matters simple reference set (foundation
metadata concept)|
|
|
|
0 … 1 |
prsb03-dataelement-13444 link |
|
Free text field to be used if no coded text available |
|
|
0 … 1 |
prsb03-dataelement-10464 link |
|
The record of essential physiological measurements, e.g., heart rate, blood pressure,
temperature, pulse, height, weight, respiratory rate, oxygen saturation.
|
|
|
|
|
Observations record entry |
|
0 … * |
prsb03-dataelement-13866 link |
|
This is an observations record entry. There may be 0 to many record entry/entries
under a section. Each record entry is made up of a number of elements or data items.
|
|
|
0 … 1 |
prsb03-dataelement-13447 link |
|
The coded value for observationsSNOMED CT: - <363787002 | Observable entity (observable entity) |
|
|
|
0 … 1 |
prsb03-dataelement-13832 link |
|
The measured value of the observationsEnumerated value e.g. numeric, natural numbers, mild, moderate |
|
|
0 … 1 |
prsb03-dataelement-13833 link |
|
The units of measure for the observation.UCUM code |
|
|
0 … 1 |
prsb03-dataelement-13848 link |
|
The anatomical site at which the observation is takenSNOMED CT: - 442083009 | Anatomical or acquired body structure (body structure) | |
|
|
0 … 1 |
prsb03-dataelement-13843 link |
|
The assessment made based on the result of the observation e.g high, lowFHIR value set: - Interpretation
|
|
|
0 … 1 |
prsb03-dataelement-13448 link |
|
Free text field to be used if no code is availableFree text |
|
Assessments |
|
0 … 1 |
prsb03-dataelement-262 link |
|
Details of the person's assessments |
|
|
Assessments record entry |
|
0 … * |
prsb03-dataelement-11664 link |
|
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.
|
|
|
0 … 1 |
prsb03-dataelement-10763 link |
|
The date the assessment was done.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-10764 link |
|
The location where the assessment was done.ODS code or free text. |
|
|
0 … 1 |
prsb03-dataelement-13570 link |
|
The coded value for locationNHS data dictionary: - Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-13571 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-10822 link |
|
The type of the assessment e.g. social care needs assessment.Free text |
|
|
0 … 1 |
prsb03-dataelement-10754 link |
|
The summary of the assessmentFree text |
|
|
0 … 1 |
prsb03-dataelement-10655 link |
|
Details of the structured assessment. |
|
|
|
|
Structured assessment name |
|
0 … 1 |
prsb03-dataelement-11751 link |
|
Structured assessment name e.g. New York Heart Failure, Glasgow Coma scale, Activities
of Daily Living (ADL) etc.SNOMED CT
|
|
|
0 … 1 |
prsb03-dataelement-10162 link |
|
The structured assessment score.Free text. |
|
|
0 … 1 |
prsb03-dataelement-10163 link |
|
The structured assessment value.Numeric |
|
|
0 … * |
prsb03-dataelement-10169 link |
|
The subscale score of the structured assessment.Free text. |
|
|
0 … * |
prsb03-dataelement-10170 link |
|
The subscale value of the structured assessment.Numeric |
|
|
0 … 1 |
prsb03-dataelement-12382 link |
|
The professional who did the assessment. |
|
|
0 … 1 |
prsb03-dataelement-12383 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-12384 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
|
0 … 1 |
prsb03-dataelement-12385 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-12386 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-12387 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-12388 link |
|
The name of the organisation the professional works for. |
|
|
0 … 1 |
prsb03-dataelement-12389 link |
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
|
0 … 1 |
prsb03-dataelement-11752 link |
|
Details of the person completing the record. |
|
|
0 … 1 |
prsb03-dataelement-11753 link |
|
The name of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11754 link |
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
|
0 … 1 |
prsb03-dataelement-11755 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11756 link |
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-11757 link |
|
The organisation the person completing the record works for.
NHS data dictionary : -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-11758 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-11759 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-11760 link |
|
Contact details of the person completing the record.
NHS data dictionary : - UK telephone number
|
|
|
0 … 1 |
prsb03-dataelement-10164 link |
|
Supporting text may be given regarding the assessment.Free text |
|
Risks |
|
0 … 1 |
prsb03-dataelement-276 link |
|
Details of any risks related to the person. |
|
|
Risks to self |
|
0 … * |
prsb03-dataelement-10176 link |
|
Details of the persons risk to self |
|
|
0 … 1 |
prsb03-dataelement-11893 link |
|
The start date of the risk.Date and time |
|
|
0 … 1 |
prsb03-dataelement-11894 link |
|
The date the risk ended.Date and time |
|
|
0 … 1 |
prsb03-dataelement-13579 link |
|
Risks the person poses to themselves, e.g. suicide, overdose, self-harm, self-neglect.SNOMED CT: - <281694009 |Finding of at risk (finding)|
|
|
|
0 … 1 |
prsb03-dataelement-11895 link |
|
The location where the risk was identified. |
|
|
0 … 1 |
prsb03-dataelement-13586 link |
|
The coded value for locationNHS data dictionary : - Organisation service code
|
|
|
0 … 1 |
prsb03-dataelement-13587 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-11896 link |
|
The professional who identified the risk. |
|
|
0 … 1 |
prsb03-dataelement-11897 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11898 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
|
0 … 1 |
prsb03-dataelement-11899 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-11900 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-11901 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-11902 link |
|
The name of the organisation the professional works for. |
|
|
0 … 1 |
prsb03-dataelement-11903 link |
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
|
0 … 1 |
prsb03-dataelement-11904 link |
|
Details of the person completing the record. |
|
|
0 … 1 |
prsb03-dataelement-11905 link |
|
The name of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11906 link |
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
|
0 … 1 |
prsb03-dataelement-11907 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11908 link |
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-11909 link |
|
The organisation the person completing the record works for.
NHS data dictionary : -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-11910 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-11911 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-11912 link |
|
Contact details of the person completing the record.
NHS data dictionary : - UK telephone number
|
|
|
Risks to others |
|
0 … * |
prsb03-dataelement-10177 link |
|
Details of the person's risk to others |
|
|
0 … 1 |
prsb03-dataelement-11913 link |
|
The start date of the risk.Date and time |
|
|
0 … 1 |
prsb03-dataelement-11914 link |
|
The date the risk ended.Date and time |
|
|
0 … 1 |
prsb03-dataelement-13580 link |
|
Risks to professionals or others.SNOMED CT: - <<391155006 |At risk of harming others (finding)|
|
|
|
0 … 1 |
prsb03-dataelement-11915 link |
|
The location where the risk to others was identified. |
|
|
0 … 1 |
prsb03-dataelement-13588 link |
|
The coded value for locationNHS data dictionary : - Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-13589 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-11916 link |
|
The professional who identifies the risk to others. |
|
|
0 … 1 |
prsb03-dataelement-11917 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11918 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
|
0 … 1 |
prsb03-dataelement-11919 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-11920 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-11921 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-11922 link |
|
The name of the organisation the professional works for. |
|
|
0 … 1 |
prsb03-dataelement-11923 link |
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
|
0 … 1 |
prsb03-dataelement-11924 link |
|
Details of the person completing the record. |
|
|
0 … 1 |
prsb03-dataelement-11925 link |
|
The name of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11926 link |
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
|
0 … 1 |
prsb03-dataelement-11927 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11928 link |
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-11929 link |
|
The organisation the person completing the record works for.
NHS data dictionary : -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-11930 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-11931 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-11932 link |
|
Contact details of the person completing the record.
NHS data dictionary : - UK telephone number
|
|
|
Risk from others |
|
0 … * |
prsb03-dataelement-10178 link |
|
Risks to the person from an identified individual e.g. family member etc.Free Text. |
|
|
0 … 1 |
prsb03-dataelement-11933 link |
|
The start date of the risk.Date and time |
|
|
0 … 1 |
prsb03-dataelement-11934 link |
|
The date the risk ended.Date and time |
|
|
0 … 1 |
prsb03-dataelement-13581 link |
|
Risks to the person from an identified individual e.g. family member etc.SNOMED CT: - <281694009 |Finding of at risk (finding)|
|
|
|
0 … 1 |
prsb03-dataelement-11935 link |
|
The location where the risk from others was identified. |
|
|
0 … 1 |
prsb03-dataelement-13590 link |
|
The coded value for locationNHS data dictionary : - Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-13591 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-11936 link |
|
The professional who identified the risk from others. |
|
|
0 … 1 |
prsb03-dataelement-11937 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11938 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
|
0 … 1 |
prsb03-dataelement-11939 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-11940 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-11941 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-11942 link |
|
The name of the organisation the professional works for. |
|
|
0 … 1 |
prsb03-dataelement-11943 link |
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
|
0 … 1 |
prsb03-dataelement-11944 link |
|
Details of the person completing the record. |
|
|
0 … 1 |
prsb03-dataelement-11945 link |
|
The name of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11946 link |
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
|
0 … 1 |
prsb03-dataelement-11947 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11948 link |
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-11949 link |
|
The organisation the person completing the record works for.
NHS data dictionary : -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-11950 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-11951 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-11952 link |
|
Contact details of the person completing the record.
NHS data dictionary : - UK telephone number
|
|
|
Risk of accidents |
|
0 … * |
prsb03-dataelement-10751 link |
|
Details of the risks the person poses to themselves from accidents. |
|
|
0 … 1 |
prsb03-dataelement-11953 link |
|
The start date of the risk.Date and time |
|
|
0 … 1 |
prsb03-dataelement-11954 link |
|
The date the risk ended.Date and time |
|
|
0 … 1 |
prsb03-dataelement-13582 link |
|
Risks the person poses to themselves from accidents.Free text |
|
|
0 … 1 |
prsb03-dataelement-11955 link |
|
The location where the risk of accidents was identified. |
|
|
0 … 1 |
prsb03-dataelement-13592 link |
|
The coded value for locationNHS data dictionary : - Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-13593 link |
|
Free text field to be used if no coded text available |
|
|
0 … 1 |
prsb03-dataelement-11956 link |
|
The professional who identified the risk of accidents. |
|
|
0 … 1 |
prsb03-dataelement-11957 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11958 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
|
0 … 1 |
prsb03-dataelement-11959 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-11960 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-11961 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-11962 link |
|
The name of the organisation the professional works for. |
|
|
0 … 1 |
prsb03-dataelement-11963 link |
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
|
0 … 1 |
prsb03-dataelement-11964 link |
|
Details of the person completing the record. |
|
|
0 … 1 |
prsb03-dataelement-11965 link |
|
The name of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11966 link |
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
|
0 … 1 |
prsb03-dataelement-11967 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11968 link |
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-11969 link |
|
The organisation the person completing the record works for.
NHS data dictionary : -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-11970 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-11971 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-11972 link |
|
Contact details of the person completing the record.
NHS data dictionary : - UK telephone number
|
|
|
Other risks |
|
0 … * |
prsb03-dataelement-10802 link |
|
Details of other risks, factors or behaviours relating to the person. |
|
|
0 … 1 |
prsb03-dataelement-11973 link |
|
The start date of the risk.Date and time |
|
|
0 … 1 |
prsb03-dataelement-11974 link |
|
The date the risk ended.Date and time |
|
|
0 … 1 |
prsb03-dataelement-13583 link |
|
Other risks, factors or behaviours relating to the person.Free text |
|
|
0 … 1 |
prsb03-dataelement-11975 link |
|
The location where the other risks were identified. |
|
|
0 … 1 |
prsb03-dataelement-13594 link |
|
The coded value for locationNHS data dictionary : - Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-13595 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-11976 link |
|
The professional who identified the other risks. |
|
|
0 … 1 |
prsb03-dataelement-11977 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11978 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
|
0 … 1 |
prsb03-dataelement-11979 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-11980 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-11981 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-11982 link |
|
The name of the organisation the professional works for. |
|
|
0 … 1 |
prsb03-dataelement-11983 link |
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
|
0 … 1 |
prsb03-dataelement-11984 link |
|
Details of the person completing the record. |
|
|
0 … 1 |
prsb03-dataelement-11985 link |
|
The name of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11986 link |
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
|
0 … 1 |
prsb03-dataelement-11987 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11988 link |
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-11989 link |
|
The organisation the person completing the record works for.
NHS data dictionary : -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-11990 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-11991 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-11992 link |
|
Contact details of the person completing the record.
NHS data dictionary : - UK telephone number
|
|
Allergies and adverse reactions |
|
1 … 1 Mandatory |
prsb03-dataelement-282 link |
|
Allergies and adverse reactions |
|
|
Allergies and adverse reactions record entry |
|
0 … * |
prsb03-dataelement-10657 link |
|
This is a allergies and adverse reactions record entry. There may be 1 to many record
entries under a section.
Each record entry is made up of a number of elements or data items.
|
|
|
0 … 1 |
prsb03-dataelement-10186 link |
|
The type of reaction experienced by the person (allergic, adverse, intolerance)FHIR value set :- Allergy, Intolerance
|
|
|
1 … 1 Mandatory |
prsb03-dataelement-10182 link |
|
The agent such as food, drug or substances that has caused or may cause an allergy,
intolerance or adverse reaction in this person Or “No known drug allergies or adverse
reactions” Or “Information not available”
|
|
|
0 … 1 |
prsb03-dataelement-13441 link |
|
The coded value for causative agent
dm+d:- any code from the VTM, VMP, AMP, VMPP, AMPP and ingredient concept classes
SNOMED CT : - <105590001 |Substance OR <373873005 |Pharmaceutical / biologic product|
OR <<716186003 |No known allergy| OR 196461000000101 |Transfer-degraded drug allergy|
OR 196471000000108 |Transfer-degraded non-drug allergy)
|
|
|
0 … 1 |
prsb03-dataelement-13442 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … * |
prsb03-dataelement-10658 link |
|
Details of the reaction. |
|
|
0 … 1 |
prsb03-dataelement-10190 link |
|
The date that the reaction was identified.Date and time |
|
|
0 … 1 |
prsb03-dataelement-10846 link |
|
Details of where the allergy was identified. Linked to the date of the diagnosis by
the professional.
|
|
|
0 … 1 |
prsb03-dataelement-13439 link |
|
The coded value for location.NHS data dictionary : - Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-13440 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-11665 link |
|
The substance, or a class of substances, that is considered to be responsible for
the adverse reaction.
|
|
|
0 … 1 |
prsb03-dataelement-13554 link |
|
The coded value for substanceSNOMED CT : - <105590001 | Substance (substance) | or <373873005 | Pharmaceutical
/ biologic product (product) |
|
|
|
0 … 1 |
prsb03-dataelement-13555 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-10183 link |
|
A description of the manifestation of the allergic or adverse reaction experienced
by the person. For example, skin rash.
|
|
|
0 … 1 |
prsb03-dataelement-13556 link |
|
The coded value for description of reaction.SNOMED CT: - ^1127581000000103 |Health issues simple reference set| |
|
|
0 … 1 |
prsb03-dataelement-13557 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-13844 link |
|
Date and time when manifestations showed e.g could be at home a few days earlier than
the contactDate and time
|
|
|
0 … 1 |
prsb03-dataelement-10184 link |
|
A description of the severity of the reaction. |
|
|
0 … 1 |
prsb03-dataelement-13558 link |
|
The coded value for severityFHIR value set : - Severity
|
|
|
0 … 1 |
prsb03-dataelement-13559 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-10185 link |
|
A description of the certainty that the stated causative agent caused the allergic
or adverse reaction.
|
|
|
0 … 1 |
prsb03-dataelement-13560 link |
|
The coded value for certainty.FHIR value set : - Certainty
|
|
|
0 … 1 |
prsb03-dataelement-13561 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-13856 link |
|
The route the person was exposed to the substance |
|
|
0 … 1 |
prsb03-dataelement-13857 link |
|
The coded value for route of exposureSNOMED CT: - ^999000051000001100 |ePrescribing route of administration simple reference
set|
|
|
|
0 … 1 |
prsb03-dataelement-13858 link |
|
Free text field to be used if no coded text available |
|
|
0 … 1 |
prsb03-dataelement-10189 link |
|
Any additional comment or clarification about the adverse reaction.Free text |
|
|
0 … 1 |
prsb03-dataelement-10187 link |
|
Results of investigations that confirmed the certainty of the diagnosis. Examples
might include results of skin prick allergy testsFree text
|
|
|
0 … 1 |
prsb03-dataelement-10188 link |
|
When the reaction was first experienced i.e this may not be the first this has happened.
May be a date or partial date (e.g. year) or text (e.g. during childhood)Date and time
|
|
|
0 … 1 |
prsb03-dataelement-14253 link |
|
The date the allergy was diagnosed as endedDate and time |
|
|
0 … 1 |
prsb03-dataelement-14273 link |
|
Any further comments on the person's allergies or adverse reactions.Free text |
|
|
0 … 1 |
prsb03-dataelement-12010 link |
|
The professional who identified the reaction. |
|
|
0 … 1 |
prsb03-dataelement-12011 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-12012 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
|
0 … 1 |
prsb03-dataelement-12013 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-12014 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-12015 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-12016 link |
|
The name of the organisation the professional works for. |
|
|
0 … 1 |
prsb03-dataelement-12017 link |
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
|
0 … 1 |
prsb03-dataelement-12018 link |
|
Details of the person completing the record. |
|
|
0 … 1 |
prsb03-dataelement-12019 link |
|
The name of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-12020 link |
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
|
0 … 1 |
prsb03-dataelement-12021 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-12022 link |
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-12023 link |
|
The organisation the person completing the record works for.
NHS data dictionary : -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-12024 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-12025 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-12026 link |
|
Contact details of the person completing the record.
NHS data dictionary : - UK telephone number
|
|
Medications and medical devices |
|
0 … 1 |
prsb03-dataelement-636 link |
|
Medications and medical devices |
|
|
Medication item entry |
|
0 … * |
prsb03-dataelement-10663 link |
|
All medications and devices that can be prescribed to be entered via this Medication
item entry. Handles details of continuation / addition / amendment of admission medications.
|
|
|
0 … 1 |
prsb03-dataelement-10664 link |
|
Medication item cluster |
|
|
0 … 1 |
prsb03-dataelement-10843 link |
|
The date on which the medication or medical device was prescribed.Date and time |
|
|
0 … 1 |
prsb03-dataelement-10844 link |
|
The location where the medication or the medical device was prescribed. |
|
|
0 … 1 |
prsb03-dataelement-13620 link |
|
The coded value for locationNHS data dictionary : - Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-13621 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-12002 link |
|
The professional who prescribed the medication or medical device. |
|
|
0 … 1 |
prsb03-dataelement-12003 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-12004 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
|
0 … 1 |
prsb03-dataelement-12005 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-12006 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-12007 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-12008 link |
|
The name of the organisation the professional works for. |
|
|
0 … 1 |
prsb03-dataelement-12009 link |
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
|
1 … 1 Mandatory |
prsb03-dataelement-10536 link |
|
May be generic name or brand name. |
|
|
0 … 1 |
prsb03-dataelement-13622 link |
|
The coded value for medication namedm+d:- any code from the VTM, VMP, AMP, VMPP and AMPP concept classes |
|
|
0 … 1 |
prsb03-dataelement-13623 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-10537 link |
|
The form of the medication e.g. capsule, drops, tablet, lotion etc. |
|
|
0 … 1 |
prsb03-dataelement-13624 link |
|
The coded value for form.SNOMED CT: - ^999000781000001107 | National Health Service dictionary of medicines
and devices dose form simple reference set (foundation metadata concept) |
|
|
|
0 … 1 |
prsb03-dataelement-13625 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-10538 link |
|
The route by which the medication is administered e.g. oral, IM, IV |
|
|
0 … 1 |
prsb03-dataelement-13655 link |
|
The coded value for routeSNOMED CT: - ^999000051000001100 |ePrescribing route of administration simple reference
set (foundation metadata concept)|
|
|
|
0 … 1 |
prsb03-dataelement-13656 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-10540 link |
|
The anatomical site at which the medication is to be administered. |
|
|
0 … 1 |
prsb03-dataelement-13657 link |
|
The coded value for siteSNOMED CT: - <442083009 | Anatomical or acquired body structure (body structure) |
|
|
|
0 … 1 |
prsb03-dataelement-13658 link |
|
Free text field to be used when code is not availableFree text |
|
|
0 … 1 |
prsb03-dataelement-10541 link |
|
The technique or method by which the medication is to be administered. |
|
|
0 … 1 |
prsb03-dataelement-13845 link |
|
The coded value for methodSNOMED CT : - ^999000041000001103 | ePrescribing method simple reference set (foundation
metadata concept) |
|
|
|
0 … 1 |
prsb03-dataelement-13846 link |
|
Free text field to be used if no coded text available |
|
|
|
|
Over the counter medication flag |
|
0 … 1 |
prsb03-dataelement-13379 link |
|
Indicates if the medication or device is acquired without a prescription i.e. got
by the person over the counterFlag : - Yes or No
|
|
|
|
|
Structured dose direction cluster |
|
0 … 1 |
prsb03-dataelement-11639 link |
|
A structural representation of the elements carried by the dose syntax in 'parsable
dose strength / timing' i.e. dose strength, dose timing, dose duration and maximum
dose.
|
|
|
0 … 1 |
prsb03-dataelement-10554 link |
|
A structural representation of dose amount, e.g. 20mg or 2 tablets. This element will
generally only be used when persisting data within systems with 'parsable dose directions'
being used to exchange the same information between systems. As per FHIR Dose Syntax
Implementation Guidance (NHS Digital): https://simplifier.net/guide/DoseSyntaxImplementationGuidanceforFHIRR4/Home
|
|
|
0 … 1 |
prsb03-dataelement-10555 link |
|
A slot containing a structural, computable representation of dose timing and maximum
dose. This element will generally only be used when persisting data within systems
with 'parsable dose directions' being used to exchange the same information between
systems. As per FHIR Dose Syntax Implementation Guidance (NHS Digital): https://simplifier.net/guide/DoseSyntaxImplementationGuidanceforFHIRR4/Home
Numeric
|
|
|
0 … 1 |
prsb03-dataelement-10548 link |
|
Recommendation of the time period for which the medication should be continued, including
direction not to discontinue. As per FHIR Dose Syntax Implementation Guidance (NHS
Digital): https://simplifier.net/guide/DoseSyntaxImplementationGuidanceforFHIRR4/Home
Numeric
|
|
|
|
|
|
Dose directions description |
|
0 … 1 |
prsb03-dataelement-10544 link |
|
Describes the entire medication dosage and administration directions including dose
quantity and medication frequency and optionally duration e.g. “1 tablet at night"
or “2mg at 10pm”.Free text
|
|
|
0 … 1 |
prsb03-dataelement-10545 link |
|
Allows for: requirements for adherence support, e.g. compliance aids, prompts and
packaging requirements, additional information about specific medicines e.g. where
specific brand required, person requirements, e.g. unable to swallow tablets.FHIR value set : - Additional instruction
|
|
|
0 … 1 |
prsb03-dataelement-10561 link |
|
Details of the overall course of medication. |
|
|
0 … 1 |
prsb03-dataelement-10666 link |
|
The status of this prescription.FHIR value set : - Medication status
|
|
|
0 … 1 |
prsb03-dataelement-10546 link |
|
Reason for medication being prescribed, where known.Free text |
|
|
0 … 1 |
prsb03-dataelement-10667 link |
|
The date and/or time that the medication course should begin.Date and time |
|
|
0 … 1 |
prsb03-dataelement-10557 link |
|
The date and/or time that the medication course should finish.Date and time |
|
|
|
|
|
Link to indication record |
|
0 … 1 |
prsb03-dataelement-10668 link |
|
A link to the record which contains the indication for this medication order.Free text with URL |
|
|
0 … 1 |
prsb03-dataelement-10547 link |
|
Suggestions about duration and/or review, ongoing monitoring requirements, advice
on starting, discontinuing or changing medication. Additional comment or recommendation
about the medication course e.g. 'Patient named supply', 'unlicensed medication',
'Foreign brand' or monitoring recommendationsFree text
|
|
|
|
|
Medication change summary cluster |
|
0 … 1 |
prsb03-dataelement-10568 link |
|
Records the changes made to medication. |
|
|
0 … 1 |
prsb03-dataelement-10669 link |
|
The nature of any change made to the medication.FHIR value set : Medication status
|
|
|
0 … 1 |
prsb03-dataelement-10670 link |
|
Reason for change in medication, e.g. sub-therapeutic dose, person intolerant.
SNOMED CT:- ^1127601000000107 | Healthcare matters simple reference set (foundation
metadata concept) |
|
|
|
0 … 1 |
prsb03-dataelement-10671 link |
|
The date of the change - addition, or amendmentDate and time |
|
|
0 … 1 |
prsb03-dataelement-10672 link |
|
Where a change is made to the medication i.e. one drug stopped and another started
or eg dose, frequency or route is changed.Free text
|
|
|
|
|
Total dose daily quantity |
|
0 … 1 |
prsb03-dataelement-10665 link |
|
The total daily dose of this medication. This is helpful for estimating optimal adherence
to dosing guidance. It may be computed from product/dose strength and frequency or
entered manually.Free text
|
|
|
0 … 1 |
prsb03-dataelement-11993 link |
|
Details of the person completing the record. |
|
|
0 … 1 |
prsb03-dataelement-11994 link |
|
The name of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11995 link |
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
|
0 … 1 |
prsb03-dataelement-11996 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-11997 link |
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-11998 link |
|
The organisation the person completing the record works for.
NHS data dictionary : -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-11999 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-12000 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-12001 link |
|
Contact details of the person completing the record.
NHS data dictionary : - UK telephone number
|
|
|
0 … * |
prsb03-dataelement-10583 link |
|
Medical devices |
|
|
0 … 1 |
prsb03-dataelement-10673 link |
|
Any medical device that isn't prescribed.Free text |
|
|
0 … 1 |
prsb03-dataelement-11280 link |
|
Any information regarding the medical device.Free text |
|
|
|
Medication discontinued entry |
|
0 … * |
prsb03-dataelement-10576 link |
|
Medication discontinued entry |
|
|
|
|
Name of discontinued medication |
|
1 … 1 Mandatory |
prsb03-dataelement-10577 link |
|
The name of the medication or medical device being discontinued |
|
|
0 … 1 |
prsb03-dataelement-13659 link |
|
The coded value for medication name
dm+d:- any code from the VTM, VMP, AMP, VMPP and AMPP concept classes
|
|
|
0 … 1 |
prsb03-dataelement-13660 link |
|
Amount of vaccine administered.Free text |
|
|
1 … 1 Mandatory |
prsb03-dataelement-12472 link |
|
The status of any change made to the medication. MUST CONTAIN STOPPED.FHIR value set: - Medication status
|
|
|
0 … 1 |
prsb03-dataelement-10579 link |
|
The clinical indication for any changes in medication status
SNOMED CT:- ^1127601000000107 | Healthcare matters simple reference set (foundation
metadata concept) |
|
|
|
0 … 1 |
prsb03-dataelement-10580 link |
|
The date of the discontinuationDate and time |
|
|
0 … 1 |
prsb03-dataelement-10582 link |
|
Any additional comment about the discontinuation or amendment.Free text |
|
Information and advice given |
|
0 … 1 |
prsb03-dataelement-315 link |
|
Information and advice given |
|
|
Information and advice given |
|
0 … 1 |
prsb03-dataelement-10215 link |
|
The oral or written information or advice given to the patient, carer, other authorised
representative, care professional or other third party. May include advice about actions
related to medicines or other ongoing care activities on an ‘information prescription'.
State here if there are concerns about the extent to which the patient and/or carer
understand the information provided about diagnosis, prognosis and treatment.
Free text
|
|
Distribution list |
|
0 … 1 |
prsb03-dataelement-330 link |
|
Distribution list |
|
|
Distribution list record entry |
|
0 … * |
prsb03-dataelement-10660 link |
|
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.
|
|
|
1 … 1 Mandatory |
prsb03-dataelement-10230 link |
|
The name of the person the communication is to be sent to, this can be a person or
professional.Free text
|
|
|
0 … 1 |
prsb03-dataelement-10231 link |
|
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).FHIR value set : - SDSjobrole
|
|
|
0 … 1 |
prsb03-dataelement-10232 link |
|
The grade of the recipient, if known by the sending institution, otherwise omitted.Free text |
|
|
0 … 1 |
prsb03-dataelement-10233 link |
|
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.
NHS data dictionary : - Organisation code
|
|
|
0 … 1 |
prsb03-dataelement-10234 link |
|
Team that the recipient belongs to in the context of receiving this message, or the
team acting as the recipient.Free text
|
|
|
0 … 1 |
prsb03-dataelement-13793 link |
|
The relationship of the receiver to the person for example, carer or parentFHIR value set : - Related person
|
|
Plan and requested actions |
|
0 … 1 |
prsb03-dataelement-535 link |
|
The details of planned investigations, procedures and treatment, and whether this
plan has been agreed with the person or their legitimate representative.
|
|
|
Plan and requested actions record entry |
|
0 … * |
prsb03-dataelement-10661 link |
|
This is a plan and requested actions record entry. There may be 0 to many record entries
under a section. Each record entry is made up of a number of elements or data items.
|
|
|
0 … 1 |
prsb03-dataelement-10445 link |
|
The date on which the plan and requested actions were prepared.Date and time |
|
|
0 … 1 |
prsb03-dataelement-12167 link |
|
The professional who prepared the plan and requested actions. |
|
|
0 … 1 |
prsb03-dataelement-12168 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-12169 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
|
0 … 1 |
prsb03-dataelement-12170 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-12171 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-12172 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-12173 link |
|
The name of the organisation the professional works for. |
|
|
0 … 1 |
prsb03-dataelement-12174 link |
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
|
0 … 1 |
prsb03-dataelement-10842 link |
|
The location where the plan and requested actions were prepared. |
|
|
0 … 1 |
prsb03-dataelement-13684 link |
|
The coded value for locationNHS data dictionary : - Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-13685 link |
|
Free text field to be used if no code is availableFree text |
|
|
|
Actions for professionals |
|
0 … 1 |
prsb03-dataelement-10436 link |
|
Including planned investigations, procedures and treatment for a person's identified
conditions and priorities. For each action the following should be identified:outcome
expectations, including the person’s expectations. A record of the planned and requested
actions. May be structured (table), with actions, names, dates, status, location,
strategies.Free text
|
|
|
|
Actions for person or their carer |
|
0 … 1 |
prsb03-dataelement-10437 link |
|
For each action the following should be identified:outcome expectations, including
person’s expectations. A record of the planned and requested actions. May be structured
(table), with actions, names, dates, status, location, strategies.Free text
|
|
|
|
Agreed with the person or their legitimate representative |
|
0 … 1 |
prsb03-dataelement-10438 link |
|
Indicates whether the person or their legitimate representative has agreed the entire
plan or individual aspects of treatment, expected outcomes, risks and alternative
treatments. A record of the agreement of the decisions made.Free text
|
|
|
|
Outcome of plan and requested actions |
|
0 … * |
prsb03-dataelement-10950 link |
|
The details of the outcome of the plan and requested actions.Free text. |
|
|
0 … 1 |
prsb03-dataelement-12175 link |
|
Details of the person completing the record. |
|
|
0 … 1 |
prsb03-dataelement-12176 link |
|
The name of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-12177 link |
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
|
0 … 1 |
prsb03-dataelement-12178 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-12179 link |
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-12180 link |
|
The organisation the person completing the record works for.
NHS data dictionary : -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-12181 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-12182 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-12183 link |
|
Contact details of the person completing the record.
NHS data dictionary : - UK telephone number
|
|
Person completing record |
|
1 … 1 Mandatory |
prsb03-dataelement-12605 link |
|
Details of the person completing the record. |
|
|
Name |
|
1 … 1 Mandatory |
prsb03-dataelement-12606 link |
|
The name of the person completing the record.Free text. |
|
|
Role |
|
1 … 1 Mandatory |
prsb03-dataelement-12607 link |
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
|
Grade |
|
0 … 1 |
prsb03-dataelement-12608 link |
|
The grade of the person completing the record.Free text. |
|
|
Specialty |
|
0 … 1 |
prsb03-dataelement-12609 link |
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
|
Professional identifier |
|
1 … 1 Mandatory |
prsb03-dataelement-12611 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
|
Date completed |
|
1 … 1 Mandatory |
prsb03-dataelement-12612 link |
|
The date and time the record was completed.Date and time. |
|
|
Contact details |
|
0 … 1 |
prsb03-dataelement-12613 link |
|
Contact details of the person completing the record.
NHS data dictionary : - UK telephone number
|
|
Care and support plan |
|
0 … 1 |
prsb03-dataelement-508 link |
|
This records the decisions reached during conversation between the individual and
health and care professional about future plans and also records progress.
|
|
|
Strengths |
|
0 … * |
prsb03-dataelement-10419 link |
|
Any strengths and assets the person has relating to their goals and hopes about their
health and well-being.
|
|
|
0 … 1 |
prsb03-dataelement-14369 link |
|
The coded value associated with the person's strengths. Could be derived from the
assessment of the person e.g. 300738008 |Able to participate in leisure activities
(finding)|
SNOMED CT : - 1127601000000107 | Healthcare matters simple reference set (foundation
metadata concept) |
|
|
|
0 … 1 |
prsb03-dataelement-14370 link |
|
Any supplementary or personalised information that relates to the person's strengths.Free text |
|
|
Needs, concerns or problems |
|
0 … * |
prsb03-dataelement-10414 link |
|
Details of the person needs, concerns or problems
|
|
|
0 … 1 |
prsb03-dataelement-14371 link |
|
The coded value associated with the person's needs, concerns or problems.SNOMED CT : - ^1127581000000103 |Health issues simple reference set|
|
|
|
0 … 1 |
prsb03-dataelement-14372 link |
|
Any supplementary or personalised information that relates to the person's needs,
concerns and problems.
|
Free text
|
|
|
0 … * |
prsb03-dataelement-10413 link |
|
The overall goals, hopes, aims or targets that the person has. Including anything
that the person wants to achieve that relates to their future health and wellbeing.
Each goal may include a description of why it is important to the person. Goals may
also be ranked in order of importance or priority to the person.
|
|
|
|
0 … 1 |
prsb03-dataelement-14373 link |
|
The coded value associated with the person's goals, aim's and hopes. e.g. 999002111000000103
|Occupational therapy goals simple reference set (foundation metadata concept)|SNOMED CT : - 413350009|Finding with explicit context|: 246090004|Associated finding|=300798006
|Able to participate in sporting activities (finding)|, 408729009|Finding context|=410518001|Goal|
|
|
|
0 … 1 |
prsb03-dataelement-14374 link |
|
Any supplementary and personalised information relating to the person's goals, aims
and hopes.Free text
|
|
|
0 … 1 |
prsb03-dataelement-14399 link |
|
Assessment of the person's motivations to achieve this goal, how important the goal
is to the person on a scale of 1-10.Numeric scale 1 - 10
|
|
|
0 … * |
prsb03-dataelement-10408 link |
|
Actions or activities the person or others plan to take to achieve the person's goals
and the resources required to do this.
|
|
|
0 … * |
prsb03-dataelement-10675 link |
|
What the action is and how it is to be carried out? |
|
|
0 … 1 |
prsb03-dataelement-14383 link |
|
The coded value for the action.
SNOMED CT : - <<71388002 |Procedure| OR <<129125009 |Procedure with explicit context|
|
|
|
0 … 1 |
prsb03-dataelement-14384 link |
|
Any supplementary and personalised information for the action.Free text |
|
|
0 … 1 |
prsb03-dataelement-10676 link |
|
Name and role (e.g. person, carer, GP, OT, etc.) of the person, or a team, carrying
out the proposed action, and, if relevant where action should take place.
|
|
|
0 … 1 |
prsb03-dataelement-14393 link |
|
The name of the professional or person carrying out the proposed action.Free text |
|
|
0 … 1 |
prsb03-dataelement-14394 link |
|
The role of the person providing the service.FHIR values set : - sdsjobrole
|
|
|
0 … 1 |
prsb03-dataelement-14395 link |
|
The name of the team.Free text |
|
|
0 … 1 |
prsb03-dataelement-14396 link |
|
Contact details of the professional (e.g. telephone number, email address etc.).Free text |
|
|
0 … 1 |
prsb03-dataelement-10677 link |
|
Planned date, time, or interval, as relevantDate and time |
|
|
0 … 1 |
prsb03-dataelement-10678 link |
|
Suggested strategies for potential problems.Free text. |
|
|
0 … 1 |
prsb03-dataelement-10679 link |
|
The status of the action or activity e.g. in progress, done, refused |
|
|
0 … 1 |
prsb03-dataelement-14385 link |
|
The coded value for the person's activity statusSNOMED CT : - ^999000081000000105 | Care planning action context values simple reference
set (foundation metadata concept) |
|
|
|
0 … 1 |
prsb03-dataelement-14386 link |
|
Any supplementary or personalised information for the person's activity statusFree text |
|
|
0 … 1 |
prsb03-dataelement-10680 link |
|
How confident the person feels to carry out the action associated to the goal.Numeric score 1 - 10 |
|
|
0 … 1 |
prsb03-dataelement-10682 link |
|
Date when action/activity record was last updatedDate and time |
|
|
0 … 1 |
prsb03-dataelement-10683 link |
|
When the action evaluation needs to be reviewed. SNOMED CT tag : - 425268008 | Review
of care plan (procedure) |Date and time.
|
|
|
0 … * |
prsb03-dataelement-10674 link |
|
Details of the person's stage goals |
|
|
0 … 1 |
prsb03-dataelement-14284 link |
|
A specific sub-goal that is related to the overall goal as agreed by the person in
collaboration with a professional.
|
|
|
0 … 1 |
prsb03-dataelement-14375 link |
|
The coded expression associated with the person's stage goal.SNOMED CT : - 413350009|Finding with explicit context|: 246090004|Associated finding|=300798006
|Able to participate in sporting activities (finding)|, 408729009|Finding context|=410518001|Goal|
|
|
|
0 … 1 |
prsb03-dataelement-14376 link |
|
Any supplementary or personalised information regarding the person's stage goal.Free text |
|
|
0 … 1 |
prsb03-dataelement-10681 link |
|
The outcome of the stage goal
|
|
|
0 … 1 |
prsb03-dataelement-14378 link |
|
The coded value for the person's stage goal outcome.SNOMED CT: - ^1127601000000107 |Healthcare matters simple reference set (foundation
metadata concept)|
|
|
|
0 … 1 |
prsb03-dataelement-14379 link |
|
Any supplementary and personalised information relating to the person's outcome.Free text |
|
|
0 … 1 |
prsb03-dataelement-14377 link |
|
The status associated with the person's stage goalSNOMED CT: - ^999000091000000107 | Care planning goal context values simple reference
set (foundation metadata concept) |
|
|
|
0 … * |
prsb03-dataelement-10416 link |
|
Outcomes of each of the person’s goals, aims and targets. Includes comments recorded
by the person, date and status.
|
|
|
0 … 1 |
prsb03-dataelement-14380 link |
|
The coded value associated with the person's overall goal outcomeSNOMED CT: - ^1127601000000107 |Healthcare matters simple reference set (foundation
metadata concept)|
|
|
|
0 … 1 |
prsb03-dataelement-14382 link |
|
Any supplementary and personalised information relating to the person's goal outcome.
Free text
|
|
|
0 … 1 |
prsb03-dataelement-14400 link |
|
The status associated with the person's overall goal.SNOMED CT: - ^999000091000000107 | Care planning goal context values simple reference
set (foundation metadata concept) |
|
|
|
Agreed with person or legitimate representative |
|
0 … 1 |
prsb03-dataelement-10409 link |
|
Indicates whether the plan was discussed and agreed with the person or legitimate
representative.
|
|
|
|
Person or legitimate representative |
|
0 … 1 |
prsb03-dataelement-14322 link |
|
Indicates whether the plan was discussed and agreed with the person or legitimate
representativePerson or legitimate representative
|
|
|
0 … 1 |
prsb03-dataelement-14323 link |
|
The full name of the person in text representation.NHS data dictionary :- Person full name
|
|
|
0 … 1 |
prsb03-dataelement-14324 link |
|
The role the professional has in relation to the person.FHIR value set : - sdsjobrole
|
|
|
Care funding source |
|
0 … 1 |
prsb03-dataelement-10410 link |
|
A reference to the funding source and any conditions or limitations associated. |
|
|
0 … 1 |
prsb03-dataelement-14391 link |
|
The organisation code of the care funding sourceNHS data dictionary : - organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-14392 link |
|
Any further information for the person's care funding source e.g. self fundedFree text |
|
|
Date this plan was last updated |
|
0 … 1 |
prsb03-dataelement-10412 link |
|
This is a record of the date that this care and support plan was last updated.Date and time |
|
|
Other care planning documents |
|
0 … * |
prsb03-dataelement-10415 link |
|
Reference other care planning documents, including the type, location and date.
This may include condition-specific plans, advance care plans, end of life care plan,
etc.Free text.
|
|
|
Planned review date/interval |
|
0 … 1 |
prsb03-dataelement-10417 link |
|
This is the date/interval when this information will next be reviewed. SNOMED CT tag
: - 425268008 | Review of care plan (procedure) |Date and time
|
|
|
Responsibility for review |
|
0 … 1 |
prsb03-dataelement-10418 link |
|
This is a record of who has responsibility for arranging review of this information.
|
|
|
0 … 1 |
prsb03-dataelement-14345 link |
|
The name of the professional with responsibility for the care of the person.Free text |
|
|
0 … 1 |
prsb03-dataelement-14346 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker, key worker, care home manager, care coordinator, LA
hospital liaison person, care home contact, hospital clinician, Independent Mental
Capacity Advocate (IMCA) etcFHIR value set : - SDSjobrole
|
|
|
0 … 1 |
prsb03-dataelement-14347 link |
|
Contact details of the professional (e.g. telephone number, email address etc.).Free text |
|
|
Location |
|
0 … 1 |
prsb03-dataelement-12044 link |
|
The location where the care and support plan was prepared. |
|
|
0 … 1 |
prsb03-dataelement-13665 link |
|
The coded value for locationNHS data dictionary: - Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-13666 link |
|
Free text field to be used if no coded text available |
|
|
Performing professional |
|
0 … 1 |
prsb03-dataelement-12027 link |
|
The professional who prepared the care and support plan. |
|
|
0 … 1 |
prsb03-dataelement-12028 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-12029 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
|
0 … 1 |
prsb03-dataelement-12030 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-12031 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-12032 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-12033 link |
|
The name of the organisation the professional works for. |
|
|
0 … 1 |
prsb03-dataelement-12034 link |
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
|
Person completing record |
|
0 … * |
prsb03-dataelement-12035 link |
|
Details of the person completing the record. |
|
|
0 … 1 |
prsb03-dataelement-12036 link |
|
The name of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-12037 link |
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
|
0 … 1 |
prsb03-dataelement-12038 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-12039 link |
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-12040 link |
|
The organisation the person completing the record works for.
NHS data dictionary : -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-12041 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-12042 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-12043 link |
|
Contact details of the person completing the record.
NHS data dictionary : - UK telephone number
|
|
Contingency plans |
|
0 … * |
prsb03-dataelement-469 link |
|
These are the things to do and people to contact, should an individual’s
health or other circumstances get worse.
|
|
|
Trigger factors |
|
1 … * Mandatory |
prsb03-dataelement-10375 link |
|
Signs to watch out for that may indicate a significant change in health or other circumstances
e.g. feeling agitated
|
|
|
0 … 1 |
prsb03-dataelement-14389 link |
|
The trigger that leads to instigation of a significant change in health or other circumstances.
SNOMED CT: - ^1127581000000103 | Health issues simple reference set (foundation metadata
concept) |
|
|
|
0 … 1 |
prsb03-dataelement-14390 link |
|
Any free text associated with the person's trigger factorFree text |
|
|
Contingency plan name |
|
0 … 1 |
prsb03-dataelement-10371 link |
|
When the action evaluation needs to be reviewed. |
|
|
0 … 1 |
prsb03-dataelement-14387 link |
|
The coded value for the type of care planSNOMED CT: - 999001471000000108 | Care plan type simple reference set (foundation
metadata concept) |
|
|
|
0 … 1 |
prsb03-dataelement-14388 link |
|
Free text if no coded value is available.Free text |
|
|
What should happen |
|
0 … * |
prsb03-dataelement-10376 link |
|
Guidance on specific actions or interventions that may be required or should be avoided
in specific situations. This may include circumstances where action needs to be taken
if a carer is unable to care for the person. A statement of suggested actions. Usually
expressed as: in the event of X do Y.
|
|
|
0 … 1 |
prsb03-dataelement-14403 link |
|
The coded value for what should happen
SNOMED CT : - <<71388002 |Procedure| OR <<129125009 |Procedure with explicit context|
|
|
|
0 … 1 |
prsb03-dataelement-14404 link |
|
Any supplementary or personalised information regarding what should happen
Free text
|
|
|
Who should be contacted |
|
0 … * |
prsb03-dataelement-10377 link |
|
Who should be contacted in the event of significant problems or deterioration in health
or wellbeing. e.g. name, role and contact details.
|
|
|
0 … 1 |
prsb03-dataelement-14405 link |
|
The name of the professional with responsibility for the care of the person.Free text |
|
|
0 … 1 |
prsb03-dataelement-14406 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker, key worker, care home manager, care coordinator, LA
hospital liaison person, care home contact, hospital clinician, Independent Mental
Capacity Advocate (IMCA) etcFHIR value set : - SDSjobrole
|
|
|
0 … 1 |
prsb03-dataelement-14407 link |
|
Contact details of the personal contact (e.g. telephone number, email address etc.)Free Text |
|
|
Agreed with person or legitimate representative |
|
0 … 1 |
prsb03-dataelement-10369 link |
|
Indicates whether the plan was discussed and agreed with the person or legitimate
representative.
|
|
|
|
Person or legitimate representative |
|
0 … 1 |
prsb03-dataelement-14339 link |
|
Indicates whether the plan was discussed and agreed with the person or legitimate
representativePerson or legitimate representative
|
|
|
0 … 1 |
prsb03-dataelement-14340 link |
|
The full name of the person in text representation.NHS data dictionary :- Person full name
|
|
|
0 … 1 |
prsb03-dataelement-14341 link |
|
The role the professional has in relation to the person.FHIR value set : - sdsjobrole
|
|
|
Date this plan was last updated |
|
0 … 1 |
prsb03-dataelement-10372 link |
|
The date that this contingency plan was last updated.Date and time |
|
|
Planned review date/interval |
|
0 … 1 |
prsb03-dataelement-10373 link |
|
This is the date/interval when this contingency plan will next be reviewed. SNOMED
CT tag : - 425268008 | Review of care plan (procedure) |Date and time
|
|
|
Responsibility for review |
|
0 … 1 |
prsb03-dataelement-10374 link |
|
This is who has responsibility for arranging review of this information.
|
|
|
0 … 1 |
prsb03-dataelement-14342 link |
|
The name of the professional with responsibility for the care of the person.Free text |
|
|
0 … 1 |
prsb03-dataelement-14343 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker, key worker, care home manager, care coordinator, LA
hospital liaison person, care home contact, hospital clinician, Independent Mental
Capacity Advocate (IMCA) etcFHIR value set : - SDSjobrole
|
|
|
0 … 1 |
prsb03-dataelement-14344 link |
|
Contact details of the professional (e.g. telephone number, email address etc.).Free text |
|
|
Coping strategies |
|
0 … * |
prsb03-dataelement-13850 link |
|
Details of coping strategies used |
|
|
0 … 1 |
prsb03-dataelement-13851 link |
|
The coping strategies are defined as thoughts and behaviours that people use to manage
the internal and external demands of situations that are appraised as stressful. This
should also include a record of any tools used to carry out the coping strategy.Free text
|
|
|
0 … 1 |
prsb03-dataelement-13852 link |
|
The date when the coping strategy startedDate and time |
|
|
0 … 1 |
prsb03-dataelement-13853 link |
|
The date when the coping strategy endedDate and time |
|
|
Relapse indicators / early warning signs |
|
0 … * |
prsb03-dataelement-13854 link |
|
Details of the relapse indicators for the person. These may also be called 'early
warning signs'
|
|
|
0 … 1 |
prsb03-dataelement-14401 link |
|
The coded value for relapse indicators/early warning signsSNOMED CT : - ^1127601000000107 | Healthcare matters simple reference set (foundation
metadata concept) |
|
|
|
0 … 1 |
prsb03-dataelement-14402 link |
|
Any supplementary or personalised information regarding the relapse indicators/early
warning signsFree text
|
|
|
Advance statement |
|
0 … 1 |
prsb03-dataelement-10777 link |
|
Written requests and preferences made by a person with capacity conveying their wishes,
beliefs and values for their future care should they lose capacity.
|
|
|
0 … 1 |
prsb03-dataelement-12267 link |
|
The date when the advanced statements was made.Date and time |
|
|
0 … 1 |
prsb03-dataelement-12268 link |
|
The location where the advanced statement was made. |
|
|
0 … 1 |
prsb03-dataelement-13698 link |
|
The coded value for locationNHS data dictionary: - Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-13699 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-13695 link |
|
Does the person have an advance statement. |
|
|
0 … 1 |
prsb03-dataelement-13696 link |
|
The coded value for advance statementSNOMED CT: - 816281000000101 | Has advance statement (Mental Capacity Act 2005) (finding)
|
|
|
|
0 … 1 |
prsb03-dataelement-13697 link |
|
Free text field to be used if no code is availableFree text |
|
|
0 … 1 |
prsb03-dataelement-13760 link |
|
The location of where the advanced statement is held.Free text or URL |
|
|
0 … 1 |
prsb03-dataelement-12269 link |
|
The professional who made the advance statement. |
|
|
0 … 1 |
prsb03-dataelement-12270 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-12271 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
|
0 … 1 |
prsb03-dataelement-12272 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-12273 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-12274 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-12275 link |
|
The name of the organisation the professional works for. |
|
|
0 … 1 |
prsb03-dataelement-12276 link |
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
|
0 … 1 |
prsb03-dataelement-12277 link |
|
Details of the person completing the record. |
|
|
0 … 1 |
prsb03-dataelement-12278 link |
|
The name of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-12279 link |
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
|
0 … 1 |
prsb03-dataelement-12280 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-12281 link |
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-12282 link |
|
The organisation the person completing the record works for.
NHS data dictionary : -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-12283 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-12284 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-12285 link |
|
Contact details of the person completing the record.
NHS data dictionary : - UK telephone number
|
|
|
Anticipatory medicines/equipment |
|
0 … * |
prsb03-dataelement-10370 link |
|
Medicines or equipment available that may be required in specific situations and their
location. A statement regarding the availability or location of the anticipatory medicines/equipment.
SNOMED CT Tag : - 871021000000106 | Prescription of palliative care anticipatory medication
(procedure) |Free text
|
|
|
Location |
|
0 … * |
prsb03-dataelement-12079 link |
|
The location where the contingency plan was prepared. |
|
|
0 … 1 |
prsb03-dataelement-13667 link |
|
The coded value for locationNHS data dictionary : - Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-13668 link |
|
Free text field to be used if no code is availableFree text |
|
|
Performing professional |
|
0 … 1 |
prsb03-dataelement-12045 link |
|
The professional who prepared the contingency plans. |
|
|
0 … 1 |
prsb03-dataelement-12046 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-12047 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
|
0 … 1 |
prsb03-dataelement-12048 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-12049 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-12050 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-12051 link |
|
The name of the organisation the professional works for. |
|
|
0 … 1 |
prsb03-dataelement-12052 link |
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
|
Person completing record |
|
0 … 1 |
prsb03-dataelement-12053 link |
|
Details of the person completing the record. |
|
|
0 … 1 |
prsb03-dataelement-12054 link |
|
The name of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-12055 link |
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
|
0 … 1 |
prsb03-dataelement-12056 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-12057 link |
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-12058 link |
|
The organisation the person completing the record works for.
NHS data dictionary : -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-12059 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-12060 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-12061 link |
|
Contact details of the person completing the record.
NHS data dictionary : - UK telephone number
|
|
Additional support plans |
|
0 … * |
prsb03-dataelement-502 link |
|
Additional support plans |
|
|
Additional support plan name |
|
0 … 1 |
prsb03-dataelement-10402 link |
|
The name of the particular additional supporting plan, e.g. dieticians plan, wound
management plan, discharge management plan and behaviour support plan.
|
|
|
0 … 1 |
prsb03-dataelement-14397 link |
|
The coded value for the type of care planSNOMED CT: - 999001471000000108 | Care plan type simple reference set (foundation
metadata concept) |
|
|
|
0 … 1 |
prsb03-dataelement-14398 link |
|
Free text if no coded value is availableFree text |
|
|
Additional support plan content |
|
0 … 1 |
prsb03-dataelement-10403 link |
|
This is the content of any additional care and support plan which the person and/or
care professional consider should be shared with others providing care and support.
May be structured in different ways, e.g. tables, diagrams, images. This is the content
of any additional care and support plan which the individual and/or care professional
consider should be shared with others providing care and support. It should be structured
as recommended for the care and support plan and if contains additional detail, it
may be referenced here.Free text
|
|
|
Planned review date/interval |
|
0 … 1 |
prsb03-dataelement-10405 link |
|
This is the date/interval when this information will next be reviewed. SNOMED CT tag
: - 425268008 | Review of care plan (procedure) |Date and time
|
|
|
Responsibility for review |
|
0 … 1 |
prsb03-dataelement-10406 link |
|
This is a record of who has responsibility for arranging review of this information.
Should include their name, role and contact details.
|
|
|
0 … 1 |
prsb03-dataelement-14348 link |
|
The name of the professional with responsibility for the care of the person.Free text |
|
|
0 … 1 |
prsb03-dataelement-14349 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker, key worker, care home manager, care coordinator, LA
hospital liaison person, care home contact, hospital clinician, Independent Mental
Capacity Advocate (IMCA) etcFHIR value set : - SDSjobrole
|
|
|
0 … 1 |
prsb03-dataelement-14350 link |
|
Contact details of the professional (e.g. telephone number, email address etc.).Free text |
|
|
Date this plan was last updated |
|
0 … 1 |
prsb03-dataelement-10407 link |
|
This is a record of the date that this information was last updated.Date and time |
|
|
Location |
|
0 … 1 |
prsb03-dataelement-12080 link |
|
The location where the additional support plan was prepared.ODS code or free text |
|
|
0 … 1 |
prsb03-dataelement-13722 link |
|
The coded value for locationNHS data dictionary:- Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-13723 link |
|
Free text field to be used if no code is availableFree text |
|
|
Performing professional |
|
0 … 1 |
prsb03-dataelement-12062 link |
|
The professional who prepared the additional support plan. |
|
|
0 … 1 |
prsb03-dataelement-12063 link |
|
The name of the professional.Free text. |
|
|
0 … 1 |
prsb03-dataelement-12064 link |
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etcFHIR value set :- SDSjobroletype
|
|
|
0 … 1 |
prsb03-dataelement-12065 link |
|
The grade of the professional.Free text |
|
|
0 … 1 |
prsb03-dataelement-12066 link |
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary - Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-12067 link |
|
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.NHS data dictionary : - Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-12068 link |
|
The name of the organisation the professional works for. |
|
|
0 … 1 |
prsb03-dataelement-12069 link |
|
Contact details of the professionalNHS data dictionary - UK phone number
|
|
|
Person completing record |
|
0 … 1 |
prsb03-dataelement-12070 link |
|
Details of the person completing the record. |
|
|
0 … 1 |
prsb03-dataelement-12071 link |
|
The name of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-12072 link |
|
The organisational role of the person completing record.FHIR value set :- SDSjobrole
|
|
|
0 … 1 |
prsb03-dataelement-12073 link |
|
The grade of the person completing the record.Free text. |
|
|
0 … 1 |
prsb03-dataelement-12074 link |
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
|
0 … 1 |
prsb03-dataelement-12075 link |
|
The organisation the person completing the record works for.
NHS data dictionary : -
Organisation data service
|
|
|
0 … 1 |
prsb03-dataelement-12076 link |
|
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
|
|
|
0 … 1 |
prsb03-dataelement-12077 link |
|
The date and time the record was completed.Date and time. |
|
|
0 … 1 |
prsb03-dataelement-12078 link |
|
Contact details of the person completing the record.
NHS data dictionary : - UK telephone number
|
Outpatient Letter
Outpatient Letter