Concept |
Card/Conf |
Id |
 |
Shared decision making |
|
0 … 1 |
prsb03-dataelement-13876 link
|
|
The details of the shared decision making process undertaken |
 |
 |
Shared decision point |
|
0 … * |
prsb03-dataelement-13877 link
|
|
This is a shared decision point 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-14096 link
|
|
Problem or issue to which the decision relates, including:
- A confirmed diagnosis.
- Examination findings.
- Outcomes from investigation results.
- Other problems or issues.
|
|
0 … * |
prsb03-dataelement-14408 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-14409 link
|
|
The coded value for the problem list.SNOMED CT : - ^1127581000000103 |Health issues simple reference set|
|
|
0 … 1 |
prsb03-dataelement-14410 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … * |
prsb03-dataelement-14077 link
|
|
Details of the encounter where a shared decision was discussed including a record
of:
Location and location type Date and time Consultation method Speciality Professionals present Person accompanying patient Use of an interpreter Recording of the conversation
|
|
0 … 1 |
prsb03-dataelement-14015 link
|
|
The specialty to which the shared decision relates e.g. physiotherapy, oncology, mental
health etcNHS data dictionary - Activity treatment function code
|
 |
 |
 |
|
Date and time of encounter |
|
0 … 1 |
prsb03-dataelement-13960 link
|
|
Date and time of the encounter where a shared decision was discussed.Date and time. |
|
0 … 1 |
prsb03-dataelement-14016 link
|
|
The type of location where the encounter in which a shared decision was discussed
took place e.g. person's homeNHS data dictionary - Location type
|
|
0 … 1 |
prsb03-dataelement-13961 link
|
|
The location of the encounter where the shared decision was discussed. |
|
0 … 1 |
prsb03-dataelement-13962 link
|
|
The coded value for location.NHS data dictionary : - Organisation data service code
|
|
0 … 1 |
prsb03-dataelement-13963 link
|
|
Free text field to be used if no code is availableFree text |
|
0 … 1 |
prsb03-dataelement-14014 link
|
|
Consultation method used e.g. face to face, telephone, video consultationNHS data dictionary - Consultation medium
|
 |
 |
 |
 |
Person accompanying patient |
|
0 … * |
prsb03-dataelement-13964 link
|
|
Identify, where relevant to the shared decision, others accompanying the patient,
e.g. parent, relative, friend. Includes: Name, Relationship, role (e.g. informal carer).
|
|
0 … 1 |
prsb03-dataelement-14008 link
|
|
The name of the person accompanying the patient. |
|
0 … 1 |
prsb03-dataelement-14009 link
|
|
The relationship the person accompanying the patient has to the person, e.g. father,
grandmother, family friend etc.FHIR value set : - Related person
|
|
0 … 1 |
prsb03-dataelement-14010 link
|
|
Additional roles the person accompanying the patient performs on behalf of the patient
(e.g. Carer, Next of Kin, Emergency Contact, Dependent, etc.)Free text.
|
|
0 … * |
prsb03-dataelement-14011 link
|
|
The name and role of the additional individuals or team members present when the shared
decision was made. Including consultant(s), nurse consultant(s), allied health professional(s),
social worker(s) etc.
|
|
0 … 1 |
prsb03-dataelement-14012 link
|
|
The name of the professional present when the shared decision was made.Free text. |
|
0 … 1 |
prsb03-dataelement-14234 link
|
|
The relationship the professional present or accompanying the patient has to the person
e.g. advocate, friend, etc.
Free text.
|
|
0 … 1 |
prsb03-dataelement-14013 link
|
|
The job title of the professional present when the shared decision was made.FHIR values set : - sdsjobrole
|
|
0 … 1 |
prsb03-dataelement-13965 link
|
|
An indicator to record whether an interpreter was used at a care contact. If yes,
records whether a professional interpreter, family member / friend, or other person
was used for the purposes of communication. If no, records whether an interpreter
was not required or did not attend.NHS data dictionary : - Interpreter present at care contact indication code
|
 |
 |
 |
 |
Audio or video recording of the conversation |
|
0 … 1 |
prsb03-dataelement-13966 link
|
|
Audio or video recording of the conversation cluster. |
 |
 |
 |
 |
|
Audio or visual recording made |
|
0 … 1 |
prsb03-dataelement-13967 link
|
|
An indicator to record if an audio or video recording was made of the conversation.SNOMED CT : - 431315003 |Audio recording of patient interview (procedure)| or 282733006
|Video recording of patient interview (procedure)|.
|
 |
 |
 |
 |
|
Consent for audio or video recording of the conversation |
|
0 … 1 |
prsb03-dataelement-13968 link
|
|
This is a record of consent for audio or visual recording of the conversation.Free text. |
 |
 |
 |
 |
|
Copy of video or audio recording |
|
0 … * |
prsb03-dataelement-13969 link
|
|
The conversation recording should be stored as a video/audio multimedia file or as
a transcript (free text).Free text or multimedia file.
|
|
0 … 1 |
prsb03-dataelement-14078 link
|
|
Details of the person completing the record. |
|
0 … 1 |
prsb03-dataelement-14079 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-14080 link
|
|
The organisational role of the person completing the record.FHIR value set :- SDSJobRoleName
|
|
0 … 1 |
prsb03-dataelement-14081 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-14082 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-14083 link
|
|
The organisation the person completing the record works for. |
|
0 … 1 |
prsb03-dataelement-14084 link
|
|
The coded value for the organisation.NHS data dictionary :- Organisational identifier
|
|
0 … 1 |
prsb03-dataelement-14085 link
|
|
Free text field to provide further detail or be used if no code is available.Free text. |
|
0 … 1 |
prsb03-dataelement-14086 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 entry identifier
|
|
0 … 1 |
prsb03-dataelement-14087 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-14088 link
|
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).NHS data dictionary :- UK telephone number
|
 |
 |
 |
Supporting the shared decision |
|
0 … 1 |
prsb03-dataelement-14073 link
|
|
A record of the interventions that have supported a shared decision. This includes
actions taken before, during and after (or in-between) appointments where a shared
decision was discussed.
|
 |
 |
 |
 |
Pre-appointment information shared |
|
0 … 1 |
prsb03-dataelement-14066 link
|
|
A record of the actions taken to prepare the patient to make a shared decision before
the encounter where a shared decision was made. This should include a summary of any
resources the person was offered to prepare them for the decision making process.Free text.
|
|
0 … 1 |
prsb03-dataelement-14074 link
|
|
A record of the actions taken to support shared decision making during the encounter. |
|
0 … 1 |
prsb03-dataelement-14095 link
|
|
A generic shared decision cluster. |
 |
 |
 |
 |
 |
 |
Decision dialogue (deliberation) |
|
0 … 1 |
prsb03-dataelement-14099 link
|
|
A record of the dialogue preceding the decision including the information shared that
a person wanted or needed to know in order to make a decision, such as:
- Diagnosis & prognosis
- Options for further investigation, treatment or management (including the option to
take no action).
- The potential benefits and risks of each option
|
 |
 |
 |
 |
 |
 |
 |
Establishing what matters to the person |
|
0 … 1 |
prsb03-dataelement-14101 link
|
|
Details of what was said about:
- Setting the agenda for the discussion.
- Establishing shared understanding of the purpose of SDM.
- The person's goals, values, hopes, ideas, concerns, and expectations related to the
shared decision.
- The person's understanding of their diagnosis.
|
|
0 … 1 |
prsb03-dataelement-14089 link
|
|
A record of the agenda setting process undertaken to support the shared decision.
This may include:
- Patient talk topic: Identifying what the patient wants to talk about in the encounter.
- Clinician talk topic: Identifying what the clinician wants to talk about in the encounter.
- Agreeing shared priorities and focus for conversation i.e. the topics that are going
to be covered.
- Establishing collaboration and engagement: Introducing the nature/purpose of the SDM
process.
- Declaring the alternative options: Listing of the possible options for treatment,
investigation, procedure, or other action; including reasonable alternatives.
|
|
0 … 1 |
prsb03-dataelement-14091 link
|
|
A record of what the patient said was their agenda (talk topic(s)) for the appointment.Free text. |
|
0 … 1 |
prsb03-dataelement-14090 link
|
|
A record of the clinician's stated agenda (talk topic(s)) for the appointment.Free text. |
 |
 |
 |
 |
 |
 |
 |
|
Person goals, values, hopes, ideas, concerns, expectations |
|
0 … 1 |
prsb03-dataelement-14102 link
|
|
A record to establish what matters to the person in the context of the decision to
be made, which may include as appropriate:
- Person goals or hopes: These are 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.
- Values: The values that the person holds relating to the decision or otherwise.
- Ideas: Opinions, thoughts, or prior knowledge the person has about their diagnosis,
prognosis, or options for treatment, investigations, procedures or other areas they
feel are relevant.
- Concerns: Any worries or fears the person has about their diagnosis (or possible diagnosis)
or other areas such as treatment, investigations or procedures that may influence
their decision-making or they feel are relevant.
- Expectations: Any expectations or wants of the person relating to treatment, investigations,
procedures or other courses of action or other areas they feel are relevant.
Free text.
|
 |
 |
 |
 |
 |
 |
 |
|
Person understanding of their condition or diagnosis |
|
0 … 1 |
prsb03-dataelement-14304 link
|
|
A record of the person's understanding of their diagnosis (or possible diagnosis)
or condition. Free text.
|
|
0 … * |
prsb03-dataelement-14285 link
|
|
Record of the options discussed. Includes:
- Option entry
- Risks communicated about the option
- Benefits communicated about the option
|
|
0 … 1 |
prsb03-dataelement-14105 link
|
|
Record of the option discussed. |
|
0 … 1 |
prsb03-dataelement-14106 link
|
|
Coded value of the option discussed.SNOMED CT. |
|
0 … 1 |
prsb03-dataelement-14107 link
|
|
Free text field to provide further detail or be used if no code is available.Free text. |
 |
 |
 |
 |
 |
 |
 |
 |
Risks communication entry |
|
0 … * |
prsb03-dataelement-14111 link
|
|
Record of the risks discussed for each option. |
|
0 … 1 |
prsb03-dataelement-14113 link
|
|
Coded value of the risk discussed.SNOMED CT. |
|
0 … 1 |
prsb03-dataelement-14112 link
|
|
Free text field to provide further detail or be used if no code is available.Free text. |
|
0 … * |
prsb03-dataelement-14108 link
|
|
Record of the benefits discussed for each option. |
|
0 … 1 |
prsb03-dataelement-14109 link
|
|
Coded value of the benefit discussed.SNOMED CT. |
|
0 … 1 |
prsb03-dataelement-14110 link
|
|
Free text field to provide further detail or be used if no code is available.Free text. |
 |
 |
 |
 |
 |
 |
 |
Decision support tool item entry |
|
0 … 1 |
prsb03-dataelement-13955 link
|
|
Record of any decision support tools used. |
 |
 |
 |
 |
 |
 |
 |
|
Decision support tool identifier |
|
0 … 1 |
prsb03-dataelement-14092 link
|
|
Any alphanumeric identifier associated with the decision support tool (if applicable). Free text. |
 |
 |
 |
 |
 |
 |
 |
|
Decision support tool name |
|
0 … 1 |
prsb03-dataelement-13956 link
|
|
The name of the decision support tool.Free text. |
 |
 |
 |
 |
 |
 |
 |
|
Decision support tool type |
|
0 … 1 |
prsb03-dataelement-13957 link
|
|
The type of the decision support tool.Free text |
 |
 |
 |
 |
 |
 |
 |
|
Decision support tool location |
|
0 … 1 |
prsb03-dataelement-13958 link
|
|
The URL for the decision support tool.Free text. |
 |
 |
 |
 |
 |
 |
 |
|
Decision support tool MIME type |
|
0 … 1 |
prsb03-dataelement-13959 link
|
|
MIME type of the document e.g. application, pdf, website.Free text. |
|
0 … 1 |
prsb03-dataelement-14114 link
|
|
Details of the decision made with person. This includes details of the decisions made
and agreed timescales for review. NB: What the person said was important to them in coming to the decision is recorded
in a separate cluster 'Evaluating the decision'.Free text.
|
|
0 … 1 |
prsb03-dataelement-14191 link
|
|
Record of the decision. |
|
0 … 1 |
prsb03-dataelement-14192 link
|
|
Coded value of the decision agreed.SNOMED CT. |
|
0 … 1 |
prsb03-dataelement-14193 link
|
|
Free text field to provide further detail or be used if no code is available.Free text. |
 |
 |
 |
 |
 |
 |
 |
|
Planned review date/interval |
|
0 … 1 |
prsb03-dataelement-14190 link
|
|
This is the date/interval when this information will next be reviewed.Date and time or free text. |
|
0 … 1 |
prsb03-dataelement-14228 link
|
|
A record of the perception of the decision and collaborative process from the perspective
of the clinician and the patient, including:
- A record of whether a mutual agreement reached.
- Did the clinician agree with the decision made? If not, what was the reason given
to the person for this.
- Was the decision made the person's preferred option?
- A record of the person's reasons for the choice made.
- A record of the person's level of satisfaction with the decision made (including decisional
regret).
|
 |
 |
 |
 |
 |
 |
 |
 |
Decision related values and preferences |
|
0 … 1 |
prsb03-dataelement-14295 link
|
|
A record of the clinician and person preferences and values that are relevant to the
decision-made.
|
 |
 |
 |
 |
 |
 |
 |
 |
 |
Person decision related values and preferences |
|
0 … 1 |
prsb03-dataelement-14297 link
|
|
A record of the person's values and preferences related to the decision-made. |
 |
 |
 |
 |
 |
 |
 |
 |
 |
|
Decision made person preference indicator |
|
0 … 1 |
prsb03-dataelement-14300 link
|
|
An indicator of whether the decision made was the person's first preference. (Yes
or No)Code. (Yes or No)
|
 |
 |
 |
 |
 |
 |
 |
 |
 |
|
Reason given to person for preference not offered |
|
0 … 1 |
prsb03-dataelement-14299 link
|
|
A description of the reasons for why a person's first preference could not be accommodated. Free text. |
|
0 … 1 |
prsb03-dataelement-14298 link
|
|
A record of the person's preferred option. |
|
0 … 1 |
prsb03-dataelement-14307 link
|
|
The coded value for the person's preferred option.SNOMED CT |
|
0 … 1 |
prsb03-dataelement-14306 link
|
|
Free text field to provide further detail or be used if no code is available.Free text. |
 |
 |
 |
 |
 |
 |
 |
 |
 |
|
Person reasons given for preference |
|
0 … 1 |
prsb03-dataelement-14296 link
|
|
An account of the reason(s) the person has given for their preference(s).Free text. |
 |
 |
 |
 |
 |
 |
 |
 |
 |
Clinician decision related values and preferences |
|
0 … 1 |
prsb03-dataelement-14301 link
|
|
A record of the clinician's relevant values and preferences that were disclosed during
the conversation.Free text.
|
 |
 |
 |
 |
 |
 |
 |
 |
 |
|
Clinician agreement with person decision indicator |
|
0 … 1 |
prsb03-dataelement-14303 link
|
|
An indicator of whether the clinician agreed with the decision made. (Yes or No).Code. (Yes or No). |
 |
 |
 |
 |
 |
 |
 |
 |
 |
|
Reason given to person for disagreement |
|
0 … 1 |
prsb03-dataelement-14302 link
|
|
Reason(s) given to the person for the clinician's recommendation/preference(s) where
they disagreed with the decision made.Free text.
|
 |
 |
 |
 |
 |
 |
 |
 |
Decision satisfaction or regret |
|
0 … 1 |
prsb03-dataelement-14231 link
|
|
A record of clinician and patient satisfaction (or regret) relating to the decision. |
 |
 |
 |
 |
 |
 |
 |
 |
|
Patient decision satisfaction |
|
0 … 1 |
prsb03-dataelement-14232 link
|
|
A record of the person's level of satisfaction (or regret) with the decision made
and the reasons for this.Free text.
|
 |
 |
 |
 |
 |
 |
 |
 |
|
Clinician decision satisfaction |
|
0 … 1 |
prsb03-dataelement-14230 link
|
|
A record of whether the clinician agreed with the patient's chosen option and the
reasons for this.Free text.
|
 |
 |
 |
 |
 |
 |
 |
Information withheld or sharing delayed |
|
0 … 1 |
prsb03-dataelement-14286 link
|
|
A structured record of the information that will be withheld or the sharing of delayed. |
 |
 |
 |
 |
 |
 |
 |
 |
Information withheld from person |
|
0 … 1 |
prsb03-dataelement-14288 link
|
|
A record of the information withheld from the person.
The General Medical Council (GMC) Decision Making and Consent guidance
(GMC, 2020) tells of 'very exceptional circumstances’ where information is withheld
because it would cause the patient ‘very serious harm’ legal advice should be sought.
|
 |
 |
 |
 |
 |
 |
 |
 |
|
Information withheld indicator |
|
0 … 1 |
prsb03-dataelement-14305 link
|
|
An indicator of whether information was withheld from the person. Yes or No.Code: Yes or No. |
 |
 |
 |
 |
 |
 |
 |
 |
 |
Information withheld indicator |
|
0 … 1 |
prsb03-dataelement-14287 link
|
|
An indicator to record that information was withheld from the person. (Yes or No)
Code (Y/N)
|
 |
 |
 |
 |
 |
 |
 |
 |
|
Reason information withheld |
|
0 … 1 |
prsb03-dataelement-14289 link
|
|
A description of the reason the information has been withheld from the person.Free text. |
|
0 … 1 |
prsb03-dataelement-14292 link
|
|
Relevant details of any legal advice sought where information has been withheld from
the person. Free text
|
 |
 |
 |
 |
 |
 |
 |
 |
Information sharing delayed |
|
0 … 1 |
prsb03-dataelement-14290 link
|
|
Details of where information sharing with the person has been delayed. |
 |
 |
 |
 |
 |
 |
 |
 |
|
Information still to share |
|
0 … 1 |
prsb03-dataelement-14294 link
|
|
Details of the information that still needs to be shared.Free text. |
 |
 |
 |
 |
 |
 |
 |
 |
|
Reasons for not sharing the information now |
|
0 … 1 |
prsb03-dataelement-14293 link
|
|
An account of the professional's reason(s) for not sharing the information with the
person during the encounterFree text.
|
 |
 |
 |
 |
 |
 |
 |
 |
|
When the information can be shared |
|
0 … 1 |
prsb03-dataelement-14291 link
|
|
A explanation of what needs to happens so that the information can be shared.Free text. |
|
0 … 1 |
prsb03-dataelement-14115 link
|
|
The professional who conducted the shared decision making conversation. |
|
0 … 1 |
prsb03-dataelement-14116 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-14117 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-14118 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etc.FHIR value set:- SDSjobrolename
|
|
0 … 1 |
prsb03-dataelement-14119 link
|
|
The grade of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-14120 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etc.NHS data dictionary :- Care professional main speciality code
|
|
0 … 1 |
prsb03-dataelement-14121 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 entry identifier
|
|
0 … 1 |
prsb03-dataelement-14122 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-14123 link
|
|
The coded value for the organisation.NHS data dictionary :- Organisation identifier
|
|
0 … 1 |
prsb03-dataelement-14124 link
|
|
Free text field to provide further detail or be used if no code is available.Free text. |
|
0 … 1 |
prsb03-dataelement-14125 link
|
|
Contact details of the professional.NHS data dictionary :- UK telephone number
|
|
0 … 1 |
prsb03-dataelement-14126 link
|
|
Details of the person completing the record. |
|
0 … 1 |
prsb03-dataelement-14127 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-14128 link
|
|
The organisational role of the person completing the record.FHIR value set :- SDSJobRoleName
|
|
0 … 1 |
prsb03-dataelement-14129 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-14130 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-14131 link
|
|
The organisation the person completing the record works for. |
|
0 … 1 |
prsb03-dataelement-14132 link
|
|
The coded value for the organisation.NHS data dictionary :- Organisational identifier
|
|
0 … 1 |
prsb03-dataelement-14133 link
|
|
Free text field to provide further detail or be used if no code is available.Free text. |
|
0 … 1 |
prsb03-dataelement-14134 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 entry identifier
|
|
0 … 1 |
prsb03-dataelement-14135 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-14136 link
|
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).NHS data dictionary :- UK telephone number
|
 |
 |
 |
 |
 |
Ask 3 questions model cluster |
|
0 … 1 |
prsb03-dataelement-14019 link
|
|
A structured entry in the record for use when a shared decision making conversation
has been conducted using the 'Ask 3 questions' framework. This patient focused shared
decision making tool encourages the patient to ask the following three questions when
making decisions about their healthcare:
What are my options?
What are the pros and cons of each option for me?
How do I get support to help me make a decision that is right for me?
|
 |
 |
 |
 |
 |
|
Ask 3 questions item entry 1 |
|
0 … 1 |
prsb03-dataelement-14020 link
|
|
A record of what was discussed following the patient asking the question 'What are
my options?' (Ask 3 questions framework).
Free text.
|
 |
 |
 |
 |
 |
|
Ask 3 questions item entry 2 |
|
0 … 1 |
prsb03-dataelement-14021 link
|
|
A record of what was discussed following the patient asking the question 'What are
the pros and cons of each option for me?' (Ask 3 questions framework).
Free text.
|
 |
 |
 |
 |
 |
|
Ask 3 questions item entry 3 |
|
0 … 1 |
prsb03-dataelement-14022 link
|
|
A record of what was discussed following the patient asking the question ' What are
my options?' (Ask 3 questions framework).
Free text.
|
|
0 … 1 |
prsb03-dataelement-14024 link
|
|
The professional who conducted the shared decision making conversation (Ask 3 questions
framework).
|
|
0 … 1 |
prsb03-dataelement-14045 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-14046 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-14047 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etc.FHIR value set:- SDSjobrolename
|
|
0 … 1 |
prsb03-dataelement-14048 link
|
|
The grade of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-14049 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etc.NHS data dictionary :- Care professional main speciality code
|
|
0 … 1 |
prsb03-dataelement-14050 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 entry identifier
|
|
0 … 1 |
prsb03-dataelement-14051 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-14052 link
|
|
The coded value for the organisation.NHS data dictionary :- Organisation identifier
|
|
0 … 1 |
prsb03-dataelement-14053 link
|
|
Free text field to provide further detail or be used if no code is available.Free text. |
|
0 … 1 |
prsb03-dataelement-14054 link
|
|
Contact details of the professional.NHS data dictionary :- UK telephone number
|
|
0 … 1 |
prsb03-dataelement-14055 link
|
|
Details of the person completing the record. |
|
0 … 1 |
prsb03-dataelement-14056 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-14057 link
|
|
The organisational role of the person completing the record.FHIR value set :- SDSJobRoleName
|
|
0 … 1 |
prsb03-dataelement-14058 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-14059 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-14060 link
|
|
The organisation the person completing the record works for. |
|
0 … 1 |
prsb03-dataelement-14061 link
|
|
The coded value for the organisation.NHS data dictionary :- Organisational identifier
|
|
0 … 1 |
prsb03-dataelement-14062 link
|
|
Free text field to provide further detail or be used if no code is available.Free text. |
|
0 … 1 |
prsb03-dataelement-14063 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 entry identifier
|
|
0 … 1 |
prsb03-dataelement-14064 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-14065 link
|
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).NHS data dictionary :- UK telephone number
|
|
0 … 1 |
prsb03-dataelement-13879 link
|
|
A structured entry in the record for clinicians following the BRAN or BRAIN approach
to shared decision making. The BRAN mnemonic covers the following:
B = Benefits
R = Risks
A = Alternatives
N = doing Nothing
Alternatively, the BRAIN mnemonic covers the following:
B = Benefits
R = Risks
A = Alternatives
I = Intuition
N = Next steps (as opposed to 'doing Nothing' in BRAN)
|
|
0 … * |
prsb03-dataelement-13880 link
|
|
A record of the benefits discussed as part of the shared decision making conversation
(BRAN or BRAIN framework).
|
|
0 … 1 |
prsb03-dataelement-13885 link
|
|
Coded value of the benefits discussed.SNOMED CT. |
|
0 … 1 |
prsb03-dataelement-13886 link
|
|
Free text field to provide further detail or be used if no code is available.Free text. |
|
0 … * |
prsb03-dataelement-13881 link
|
|
A record of the risks discussed as part of the shared decision making conversation
(BRAN or BRAIN framework).
|
|
0 … 1 |
prsb03-dataelement-13887 link
|
|
Coded value of the risks discussed.SNOMED CT. |
|
0 … 1 |
prsb03-dataelement-13888 link
|
|
Free text field to provide further detail or be used if no code is available.Free text. |
|
0 … * |
prsb03-dataelement-13882 link
|
|
A record of the alternatives discussed as part of the shared decision making conversation
(BRAN or BRAIN framework).
|
|
0 … 1 |
prsb03-dataelement-13889 link
|
|
Coded value of the alternatives discussed.SNOMED CT. |
|
0 … 1 |
prsb03-dataelement-13890 link
|
|
Free text field to provide further detail or be used if no code is available.Free text. |
|
0 … 1 |
prsb03-dataelement-13891 link
|
|
A record of the person's intuition (BRAIN framework).Free text. |
|
0 … 1 |
prsb03-dataelement-13884 link
|
|
An indicator showing whether the option to do nothing was discussed as part of the
shared decision making conversation (BRAN framework).
|
|
0 … 1 |
prsb03-dataelement-13892 link
|
|
Coded value to indicate whether the option to do nothing was discussed.Y = yes ; N = no |
|
0 … 1 |
prsb03-dataelement-13893 link
|
|
Free text field to provide further detail or be used if no code is available.Free text. |
|
0 … 1 |
prsb03-dataelement-13894 link
|
|
A record of the next steps considered (BRAIN framework). |
|
0 … 1 |
prsb03-dataelement-13895 link
|
|
A record of the decision made (BRAN or BRAIN framework).Free text. |
|
0 … 1 |
prsb03-dataelement-13896 link
|
|
The professional who conducted the shared decision making conversation (BRAN or BRAIN
framework).
|
|
0 … 1 |
prsb03-dataelement-13897 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-13898 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etc.FHIR value set:- SDSjobrolename
|
|
0 … 1 |
prsb03-dataelement-13899 link
|
|
The grade of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-13900 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etc.NHS data dictionary :- Care professional main speciality code
|
|
0 … 1 |
prsb03-dataelement-13901 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 entry identifier
|
|
0 … 1 |
prsb03-dataelement-13903 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-13904 link
|
|
The coded value for the organisation.NHS data dictionary :- Organisation identifier
|
|
0 … 1 |
prsb03-dataelement-13905 link
|
|
Free text field to provide further detail or be used if no code is available.Free text. |
|
0 … 1 |
prsb03-dataelement-13906 link
|
|
Contact details of the professional.NHS data dictionary :- UK telephone number
|
|
0 … 1 |
prsb03-dataelement-13907 link
|
|
Details of the person completing the record. |
|
0 … 1 |
prsb03-dataelement-13908 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-13909 link
|
|
The organisational role of the person completing the record.FHIR value set :- SDSJobRoleName
|
|
0 … 1 |
prsb03-dataelement-13910 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-13911 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-13912 link
|
|
The organisation the person completing the record works for. |
|
0 … 1 |
prsb03-dataelement-13913 link
|
|
The coded value for the organisation.NHS data dictionary :- Organisational identifier
|
|
0 … 1 |
prsb03-dataelement-13914 link
|
|
Free text field to provide further detail or be used if no code is available.Free text. |
|
0 … 1 |
prsb03-dataelement-13915 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 entry identifier
|
|
0 … 1 |
prsb03-dataelement-13916 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-13917 link
|
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).NHS data dictionary :- UK telephone number
|
|
0 … 1 |
prsb03-dataelement-13918 link
|
|
A structured entry in the record for clinicians following the three talk model approach
to shared decision making.
|
|
0 … 1 |
prsb03-dataelement-13919 link
|
|
Details of the team talk (previously choice talk) with the person (Three talk model). |
|
0 … 1 |
prsb03-dataelement-13920 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.Free text.
|
 |
 |
 |
 |
 |
 |
|
Information and advice given |
|
0 … 1 |
prsb03-dataelement-13921 link
|
|
A description of pertinent aspects, including the information and advice given to
the person as part of the team talk. This should include any decision support tools
used and where a copy of these can be securely obtained.Free text.
|
|
0 … 1 |
prsb03-dataelement-13922 link
|
|
Details of the option talk with the person (Three talk model). |
|
0 … * |
prsb03-dataelement-13923 link
|
|
Record of the options discussed. |
|
0 … 1 |
prsb03-dataelement-13924 link
|
|
Coded value of the option discussed.SNOMED CT. |
|
0 … 1 |
prsb03-dataelement-13925 link
|
|
Free text field to provide further detail or be used if no code is available.Free text. |
|
0 … 1 |
prsb03-dataelement-13926 link
|
|
Record of the benefits discussed for each option. |
|
0 … 1 |
prsb03-dataelement-13927 link
|
|
Coded value of the benefit discussed.SNOMED CT. |
|
0 … 1 |
prsb03-dataelement-13928 link
|
|
Free text field to provide further detail or be used if no code is available.Free text. |
 |
 |
 |
 |
 |
 |
 |
Risks communication entry |
|
0 … * |
prsb03-dataelement-13929 link
|
|
Record of the risks discussed for each option. |
|
0 … 1 |
prsb03-dataelement-13930 link
|
|
Coded value of the risk discussed.SNOMED CT. |
|
0 … 1 |
prsb03-dataelement-13931 link
|
|
Free text field to provide further detail or be used if no code is available.Free text. |
|
0 … 1 |
prsb03-dataelement-13932 link
|
|
Details of the decision talk with the person. This includes details of the decisions
made, what the person said was important to them in coming to the decision, and agreed
timescales for review.Free text.
|
|
0 … 1 |
prsb03-dataelement-13933 link
|
|
The professional who conducted the shared decision making conversation (Three talk
model).
|
|
0 … 1 |
prsb03-dataelement-13935 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-13936 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etc.FHIR value set:- SDSjobrolename
|
|
0 … 1 |
prsb03-dataelement-13937 link
|
|
The grade of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-13938 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etc.NHS data dictionary :- Care professional main speciality code
|
|
0 … 1 |
prsb03-dataelement-13939 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 entry identifier
|
|
0 … 1 |
prsb03-dataelement-13940 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-13941 link
|
|
The coded value for the organisation.NHS data dictionary :- Organisation identifier
|
|
0 … 1 |
prsb03-dataelement-13942 link
|
|
Free text field to provide further detail or be used if no code is available.Free text. |
|
0 … 1 |
prsb03-dataelement-13943 link
|
|
Contact details of the professional.NHS data dictionary :- UK telephone number
|
|
0 … 1 |
prsb03-dataelement-13944 link
|
|
Details of the person completing the record. |
|
0 … 1 |
prsb03-dataelement-13945 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-13946 link
|
|
The organisational role of the person completing the record.FHIR value set :- SDSJobRoleName
|
|
0 … 1 |
prsb03-dataelement-13947 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-13948 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-13949 link
|
|
The organisation the person completing the record works for. |
|
0 … 1 |
prsb03-dataelement-13950 link
|
|
The coded value for the organisation.NHS data dictionary :- Organisational identifier
|
|
0 … 1 |
prsb03-dataelement-13951 link
|
|
Free text field to provide further detail or be used if no code is available.Free text. |
|
0 … 1 |
prsb03-dataelement-13952 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 entry identifier
|
|
0 … 1 |
prsb03-dataelement-13953 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-13954 link
|
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).NHS data dictionary :- UK telephone number
|
|
0 … 1 |
prsb03-dataelement-14076 link
|
|
A record of the actions agreed to support the shared decision after the appointment.
This should include:
Agreed actions for the professional such as those related to further information to
be shared, planned investigations, procedures and treatment for a person's identified
conditions and priorities.
Actions for the person or their carer. For example, following clinician shared printouts
summarising the options or decisions made and there may be action for patient to review
. Following clinician signposting to relevant online or physical information resources
there may be an agreed action for the person to access and review the materials.Free text.
|
 |
 |
 |
 |
|
Actions for professionals |
|
0 … 1 |
prsb03-dataelement-14188 link
|
|
Agreed actions for the professional including planned investigations, procedures and
treatment for a person's identified conditions and priorities.Free text.
|
 |
 |
 |
 |
|
Actions for person or their carer |
|
0 … 1 |
prsb03-dataelement-14189 link
|
|
Agreed actions for the person or their carer. For each action the following should
be identified: outcome expectations, including person’s expectations.Free text.
|
|
0 … 1 |
prsb03-dataelement-14194 link
|
|
A record of documents recording consent for an intervention. |
 |
 |
 |
 |
Consent for procedure record entry |
|
0 … * |
prsb03-dataelement-14195 link
|
|
This is a consent for 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-14196 link
|
|
The date when consent was taken.Date and time. |
|
0 … 1 |
prsb03-dataelement-14197 link
|
|
The location where consent was taken. |
|
0 … 1 |
prsb03-dataelement-14198 link
|
|
The coded value for location.NHS data dictionary : - Organisation data service code
|
|
0 … 1 |
prsb03-dataelement-14199 link
|
|
Free text field to provide further detail or be used if no code is available.Free text. |
|
0 … 1 |
prsb03-dataelement-14200 link
|
|
Record of consent form used.
|
|
0 … 1 |
prsb03-dataelement-14201 link
|
|
The coded value for the consent form used.SNOMED CT : - SNOMED CT: - : 849771000000105 |Obtaining consent using form 1 (patient
agreement to investigation or treatment) (procedure)| OR 849781000000107 |Obtaining
consent using form 2 (parental agreement to investigation or treatment for a child
or young person) (procedure)| OR 849791000000109 |Obtaining consent using form 3 (patient
or parental agreement to investigation or treatment) (procedure)| OR 849801000000108
|Obtaining consent using form 4 (adults who are unable to consent to investigation
or treatment) (procedure)|
|
|
0 … 1 |
prsb03-dataelement-14202 link
|
|
Free text field to provide further detail or be used if no code is available.Free text. |
|
0 … 1 |
prsb03-dataelement-14203 link
|
|
The URL for the consent form.Free text. |
|
0 … 1 |
prsb03-dataelement-14204 link
|
|
MIME type of the document e.g. application, pdf, website.Free text. |
|
0 … 1 |
prsb03-dataelement-14206 link
|
|
The professional who completed the consent form. |
|
0 … 1 |
prsb03-dataelement-14207 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-14208 link
|
|
The name of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-14209 link
|
|
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etc.FHIR value set:- SDSjobrolename
|
|
0 … 1 |
prsb03-dataelement-14210 link
|
|
The grade of the professional.Free text. |
|
0 … 1 |
prsb03-dataelement-14211 link
|
|
The specialty of the professional e.g. physiotherapy, oncology, mental health etc.NHS data dictionary :- Care professional main speciality code
|
|
0 … 1 |
prsb03-dataelement-14212 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 entry identifier
|
|
0 … 1 |
prsb03-dataelement-14213 link
|
|
The name of the organisation the professional works for. |
|
0 … 1 |
prsb03-dataelement-14214 link
|
|
The coded value for the organisation.NHS data dictionary :- Organisation identifier
|
|
0 … 1 |
prsb03-dataelement-14215 link
|
|
Free text field to provide further detail or be used if no code is available.Free text. |
|
0 … 1 |
prsb03-dataelement-14216 link
|
|
Contact details of the professional.NHS data dictionary :- UK telephone number
|
|
0 … 1 |
prsb03-dataelement-14217 link
|
|
Details of the person completing the record. |
|
0 … 1 |
prsb03-dataelement-14218 link
|
|
The name of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-14219 link
|
|
The organisational role of the person completing the record.FHIR value set :- SDSJobRoleName
|
|
0 … 1 |
prsb03-dataelement-14220 link
|
|
The grade of the person completing the record.Free text. |
|
0 … 1 |
prsb03-dataelement-14221 link
|
|
The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
|
|
0 … 1 |
prsb03-dataelement-14222 link
|
|
The organisation the person completing the record works for. |
|
0 … 1 |
prsb03-dataelement-14223 link
|
|
The coded value for the organisation.NHS data dictionary :- Organisational identifier
|
|
0 … 1 |
prsb03-dataelement-14224 link
|
|
Free text field to provide further detail or be used if no code is available.Free text. |
|
0 … 1 |
prsb03-dataelement-14225 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 entry identifier
|
|
0 … 1 |
prsb03-dataelement-14226 link
|
|
The date and time the record was completed.Date and time. |
|
0 … 1 |
prsb03-dataelement-14227 link
|
|
Contact details of the person completing the record (e.g. telephone number, email
address etc.).NHS data dictionary :- UK telephone number
|