| Name |
Details [‑] |
|
  Shared decision making 0 … 1
prsb03-dataelement-13876
|
|
|
| Id |
prsb03-dataelement-13876 (2021‑02‑01 16:13:46)
|
| Cardinality |
0 … 1 |
| Description |
The details of the shared decision making process undertaken |
| Comment |
Shared decision making (SDM) is a deliberative practice where individuals and clinicians
faced with a decision collaborate to understand and select evidenced based options
(such as tests, treatment, management, or support packages and including doing nothing),
and where the person is supported to develop their informed preferences.
|
 Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Shared decision point 0 … *
prsb03-dataelement-13877
|
|
|
| Id |
prsb03-dataelement-13877 (2021‑02‑01 16:17:30)
|
| Cardinality |
0 … * |
| Description |
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.
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Problem(s) or issue(s) 0 … 1
prsb03-dataelement-14096
|
|
|
| Id |
prsb03-dataelement-14096 (2021‑02‑21 15:37:38)
|
| Cardinality |
0 … 1 |
| Description |
Problem or issue to which the decision relates, including:
- A confirmed diagnosis.
- Examination findings.
- Outcomes from investigation results.
- Other problems or issues.
|
| Comment |
The problem or issue for which a shared decision was made. The problem will typically
require an investigation, treatment, procedure or lifestyle intervention or a change
to these e.g. starting, stopping, or switching a prescribed medication. Medical problems
or issues would include signs, symptoms, a diagnosis, risk factors, examination findings
or investigation results, or other issues.
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Problem 0 … *
prsb03-dataelement-14408
|
|
|
| Id |
prsb03-dataelement-14408 (2021‑07‑08 18:35:13)
|
| Cardinality |
0 … * |
| Concept inherits from |
prsb03-dataelement-10932 (2019‑04‑30 17:08:40)
|
| Description |
A condition which needs addressing and so is important for every professional to know
about when seeing the person.
Problems may include diagnoses, symptoms, disabilities and social or behavioural issues
|
| Relationship |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Coded value 0 … 1
prsb03-dataelement-14409
|
|
|
|
|
| Free text 0 … 1
prsb03-dataelement-14410
|
|
|
| Id |
prsb03-dataelement-14410 (2021‑07‑08 18:36:26)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13245 (2020‑07‑27 18:46:30)
|
| Description |
Free text field to be used if no code is available |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Encounter details 0 … *
prsb03-dataelement-14077
|
|
|
| Id |
prsb03-dataelement-14077 (2021‑02‑18 00:03:21)
|
| Cardinality |
0 … * |
| Description |
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
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Specialty 0 … 1
prsb03-dataelement-14015
|
|
|
| Id |
prsb03-dataelement-14015 (2021‑02‑15 11:07:47)
|
| Cardinality |
0 … 1 |
| Description |
The specialty to which the shared decision relates e.g. physiotherapy, oncology, mental
health etc
|
| Operationalization |
NHS data dictionary -
Activity treatment function code
|
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Date and time of encounter 0 … 1
prsb03-dataelement-13960
|
|
|
| Id |
prsb03-dataelement-13960 (2021‑02‑03 15:40:11)
|
| Cardinality |
0 … 1 |
| Description |
Date and time of the encounter where a shared decision was discussed. |
|
|
| Relationship |
|
| Operationalization |
Date and time. |
| Value Domain |
|
| Property |
| Timestamp precision |
| at least day, month and year, hour and minute |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Location type 0 … 1
prsb03-dataelement-14016
|
|
|
| Id |
prsb03-dataelement-14016 (2021‑02‑15 11:19:12)
|
| Cardinality |
0 … 1 |
| Description |
The type of location where the encounter in which a shared decision was discussed
took place e.g. person's home
|
| Comment |
The General Medical Council guidance on Decision making and consent states in section
27
(GMC, 2020) : "To help patients understand and retain relevant information you should: share
it in a place and at a time when they are most likely to understand and retain it."
|
| Operationalization |
NHS data dictionary -
Location type
|
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Location 0 … 1
prsb03-dataelement-13961
|
|
|
| Id |
prsb03-dataelement-13961 (2021‑02‑03 15:52:53)
|
| Cardinality |
0 … 1 |
| Description |
The location of the encounter where the shared decision was discussed. |
| Relationship |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Coded value 0 … 1
prsb03-dataelement-13962
|
|
|
| Id |
prsb03-dataelement-13962 (2021‑02‑03 15:54:29)
|
| Cardinality |
0 … 1 |
| Description |
The coded value for location. |
| Relationship |
|
| Operationalization |
NHS data dictionary : -
Organisation data service code
|
| Value Domain |
|
| Property |
| min length |
max length |
| 3 |
5 |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Free text 0 … 1
prsb03-dataelement-13963
|
|
|
| Id |
prsb03-dataelement-13963 (2021‑02‑03 15:54:29)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13514 (2020‑09‑03 18:04:13)
|
| Description |
Free text field to be used if no code is available |
| Operationalization |
Free text |
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Consultation method 0 … 1
prsb03-dataelement-14014
|
|
|
| Id |
prsb03-dataelement-14014 (2021‑02‑15 10:58:56)
|
| Cardinality |
0 … 1 |
| Description |
Consultation method used e.g. face to face, telephone, video consultation |
| Operationalization |
NHS data dictionary -
Consultation medium
|
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Person accompanying patient 0 … *
prsb03-dataelement-13964
|
|
|
| Id |
prsb03-dataelement-13964 (2021‑02‑04 09:28:42)
|
| Cardinality |
0 … * |
| Description |
Identify, where relevant to the shared decision, others accompanying the patient,
e.g. parent, relative, friend. Includes: Name, Relationship, role (e.g. informal carer).
|
| FHIR |
Encounter.participant |
|
| Relationship |
|
| Comment |
The General Medical Council (GMC) guidance on Decision making and consent
(GMC, 2020) states in section 27 "accommodate a patient’s wishes if they would like anyone else
– a relative, partner, friend, carer or advocate – to be involved in discussions and/or
help them make decisions."
The NICE guideline on Shared Decision Making (
in draft) states in section 1.2.3:
"Ask the person if they want to involve family members, friends or advocates (being
aware of safeguarding). If so, include them in discussions as a way to help the person:
• actively engage in the consultation
• explain what is important to them
• make decisions about their care
• remember information they have been given during discussions."
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Name 0 … 1
prsb03-dataelement-14008
|
|
|
| Id |
prsb03-dataelement-14008 (2021‑02‑15 10:23:49)
|
| Cardinality |
0 … 1 |
| Description |
The name of the person accompanying the patient. |
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Relationship 0 … 1
prsb03-dataelement-14009
|
|
|
| Id |
prsb03-dataelement-14009 (2021‑02‑15 10:28:38)
|
| Cardinality |
0 … 1 |
| Description |
The relationship the person accompanying the patient has to the person, e.g. father,
grandmother, family friend etc.
|
| Operationalization |
FHIR value set : -
Related person
|
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Role 0 … 1
prsb03-dataelement-14010
|
|
|
| Id |
prsb03-dataelement-14010 (2021‑02‑15 10:33:50)
|
| Cardinality |
0 … 1 |
| Description |
Additional roles the person accompanying the patient performs on behalf of the patient
(e.g. Carer, Next of Kin, Emergency Contact, Dependent, etc.)
|
| Operationalization |
Free text. |
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Professionals present 0 … *
prsb03-dataelement-14011
|
|
|
| Id |
prsb03-dataelement-14011 (2021‑02‑15 10:43:47)
|
| Cardinality |
0 … * |
| Description |
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.
|
| Comment |
The NICE guideline on Shared Decision Making (
in draft) states in section 1.2.5:
"If a person might find it difficult to share in decision making, for example if they
have a mental health condition, English is not their first language or they have sensory
difficulties, offer to arrange additional support for them if they do not have, or
do not want, support from a partner, friend or carer. Support could come from a nurse,
social worker, translator or volunteer (for example, an advocate) who can:
• help them to understand the resources provided
• encourage the person to take an active part in decision making
• reassure them that shared decision making will be supported by the healthcare professional
they see."
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Name 0 … 1
prsb03-dataelement-14012
|
|
|
| Id |
prsb03-dataelement-14012 (2021‑02‑15 10:46:55)
|
| Cardinality |
0 … 1 |
| Description |
The name of the professional present when the shared decision was made. |
| Operationalization |
Free text. |
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Relationsip 0 … 1
prsb03-dataelement-14234
|
|
|
| Id |
prsb03-dataelement-14234 (2021‑02‑26 01:41:56)
|
| Cardinality |
0 … 1 |
| Description |
The relationship the professional present or accompanying the patient has to the person
e.g. advocate, friend, etc.
|
| Operationalization |
Free text. |
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Job title 0 … 1
prsb03-dataelement-14013
|
|
|
| Id |
prsb03-dataelement-14013 (2021‑02‑15 10:49:05)
|
| Cardinality |
0 … 1 |
| Description |
The job title of the professional present when the shared decision was made. |
| Operationalization |
FHIR values set : -
sdsjobrole
|
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Use of an interpreter 0 … 1
prsb03-dataelement-13965
|
|
|
| Id |
prsb03-dataelement-13965 (2021‑02‑04 09:37:32)
|
| Cardinality |
0 … 1 |
| Description |
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.
|
| Comment |
The General Medical Council (GMC) guidance on Decision making and consent
(GMC, 2020) says in section 27e: "To help patients understand and retain relevant information
you should: use an interpreter or translation service if they have difficulty understanding
spoken English."
|
| Operationalization |
NHS data dictionary : -
Interpreter present at care contact indication code
|
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Audio or video recording of the conversation 0 … 1
prsb03-dataelement-13966
|
|
|
| Id |
prsb03-dataelement-13966 (2021‑02‑04 09:53:11)
|
| Cardinality |
0 … 1 |
| Description |
Audio or video recording of the conversation cluster. |
| Comment |
The General Medical Council (GMC) guidance on Decision making and consent states in
section 27c: "To help patients understand and retain relevant information you should:
accommodate a patient’s wishes if they would like to to record the discussion."
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Audio or visual recording made 0 … 1
prsb03-dataelement-13967
|
|
|
| Id |
prsb03-dataelement-13967 (2021‑02‑04 09:57:03)
|
| Cardinality |
0 … 1 |
| Description |
An indicator to record if an audio or video recording was made of the conversation. |
| Operationalization |
SNOMED CT : - 431315003 |Audio recording of patient interview (procedure)| or 282733006
|Video recording of patient interview (procedure)|.
|
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Consent for audio or video recording of the conversation 0 … 1
prsb03-dataelement-13968
|
|
|
| Id |
prsb03-dataelement-13968 (2021‑02‑04 10:25:25)
|
| Cardinality |
0 … 1 |
| Description |
This is a record of consent for audio or visual recording of the conversation. |
| Comment |
The General Medical Council (GMC) Making and using video recordings of patients guidance
(GMC, 2011) states in section 8 the following:
- "make recordings only where you have appropriate consent or other valid authority
for doing so."
- "ensure that patients are under no pressure to give their consent for the recording
to be made."
- "And you must not: disclose or use recordings for purposes outside the scope of the
original consent without obtaining further consent (except in the circumstances set
out [elsewhere in that document]."
The GMC guidance on Decision making and consent
(GMC, 2020) makes clear that: 'While some interventions require a patient’s signature on a form,
for most healthcare decisions you can rely on a patient’s verbal consent, as long
as you are satisfied they’ve had the opportunity to consider any relevant information
(see paragraph 10) and decided to go ahead. Although a patient can give consent verbally
(or non-verbally) you should make sure this is recorded in their notes."
|
| Operationalization |
Free text. |
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Copy of video or audio recording 0 … *
prsb03-dataelement-13969
|
|
|
| Id |
prsb03-dataelement-13969 (2021‑02‑04 10:39:30)
|
| Cardinality |
0 … * |
| Description |
The conversation recording should be stored as a video/audio multimedia file or as
a transcript (free text).
|
| Comment |
The General Medical Council (GMC) guidance on Decision making and consent
(GMC, 2020) states the following in section 23:
- "If you make a recording as part of a patient’s care you must follow our guidance
on Making and using visual and audio recordings of patients. Such recordings form
part of the medical record and should be treated in the same way as other records."
- "Recordings made by patients are owned by them and do not have to be stored with their
medical records."
|
| Operationalization |
Free text or multimedia file. |
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Person completing record 0 … 1
prsb03-dataelement-14078
|
|
|
| Id |
prsb03-dataelement-14078 (2021‑02‑18 00:44:21)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13907 (2021‑02‑02 22:27:51)
|
| Description |
Details of the person completing the record. |
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Name 0 … 1
prsb03-dataelement-14079
|
|
|
| Id |
prsb03-dataelement-14079 (2021‑02‑18 00:46:15)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13908 (2021‑02‑02 22:35:30)
|
| Description |
The name of the person completing the record. |
| Rationale |
Composition.author.Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Role 0 … 1
prsb03-dataelement-14080
|
|
|
| Id |
prsb03-dataelement-14080 (2021‑02‑18 00:46:15)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13909 (2021‑02‑02 22:37:50)
|
| Description |
The organisational role of the person completing the record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSJobRoleName
|
| Value Domain |
|
| Property |
| min length |
max length |
| 5 |
5 |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Grade 0 … 1
prsb03-dataelement-14081
|
|
|
| Id |
prsb03-dataelement-14081 (2021‑02‑18 00:46:15)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13910 (2021‑02‑02 22:42:50)
|
| Description |
The grade of the person completing the record. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Specialty 0 … 1
prsb03-dataelement-14082
|
|
|
| Id |
prsb03-dataelement-14082 (2021‑02‑18 00:46:15)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13911 (2021‑02‑02 22:47:46)
|
| Description |
The main specialty of the person completing the record. |
| FHIR |
PractitionerRole.specialty |
|
| Rationale |
PractitionerRole.specialty |
| Operationalization |
NHS data dictionary :-
Activity treatment function code
|
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Organisation 0 … 1
prsb03-dataelement-14083
|
|
|
| Id |
prsb03-dataelement-14083 (2021‑02‑18 00:46:15)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13912 (2021‑02‑02 22:55:15)
|
| Description |
The organisation the person completing the record works for. |
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Coded value 0 … 1
prsb03-dataelement-14084
|
|
|
|
|
| Free text 0 … 1
prsb03-dataelement-14085
|
|
|
| Id |
prsb03-dataelement-14085 (2021‑02‑18 00:46:15)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13914 (2021‑02‑02 23:02:16)
|
| Description |
Free text field to provide further detail or be used if no code is available. |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Professional identifier 0 … 1
prsb03-dataelement-14086
|
|
|
| Id |
prsb03-dataelement-14086 (2021‑02‑18 00:46:15)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13915 (2021‑02‑02 23:06:19)
|
| Description |
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.
|
| FHIR |
PractitionerRole.Practitioner.identifier (local) Practitioner.identifer (professional) |
|
| Rationale |
Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier
(for local role identifiers)
|
| Operationalization |
NHS data dictionary :-
Professional registration entry identifier
|
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Date completed 0 … 1
prsb03-dataelement-14087
|
|
|
| Id |
prsb03-dataelement-14087 (2021‑02‑18 00:46:15)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13916 (2021‑02‑02 23:12:04)
|
| Description |
The date and time the record was completed. |
| Rationale |
Composition.date |
| Operationalization |
Date and time. |
| Value Domain |
|
| Property |
| Timestamp precision |
| at least day, month and year, hour and minute |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Contact details 0 … 1
prsb03-dataelement-14088
|
|
|
| Id |
prsb03-dataelement-14088 (2021‑02‑18 00:46:15)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13917 (2021‑02‑02 23:16:07)
|
| Description |
Contact details of the person completing the record (e.g. telephone number, email
address etc.).
|
| FHIR |
PractitionerRole.telecom |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telecom
|
| Operationalization |
NHS data dictionary :-
UK telephone number
|
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Supporting the shared decision 0 … 1
prsb03-dataelement-14073
|
|
|
| Id |
prsb03-dataelement-14073 (2021‑02‑17 23:43:36)
|
| Cardinality |
0 … 1 |
| Description |
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.
|
| Comment |
Other interventions that support shared decision making such as use of an interpreter,
recording of the discussion, and person(s) accompanying the patient can be found under
encounter details.
The NICE guideline on Shared Decision Making (
in draft) states in section 1.2.1:
"Offer people interventions that support shared decision making at different stages,
including before, during and after discussions with a healthcare professional, so
that they are fully involved throughout their care."
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Pre-appointment information shared 0 … 1
prsb03-dataelement-14066
|
|
|
| Id |
prsb03-dataelement-14066 (2021‑02‑17 11:43:19)
|
| Cardinality |
0 … 1 |
| Description |
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.
|
| Comment |
The NICE guideline on Shared Decision Making (
in draft) states in section 1.2.4:
"Before an appointment where a decision will be discussed, offer the person access
to resources in their preferred format (for example a booklet, flyer or app) to help
them prepare for discussing options and making shared decisions. It should encourage
them to think about what matters to them and what they hope to gain from the appointment
(the 'preparation stage'). Resources could include links to relevant NICE guidance
or NICE-endorsed information."
In section 1.2.5:
"If a person might find it difficult to share in decision making, for example if they
have a mental health condition, English is not their first language or they have sensory
difficulties, offer to arrange additional support for them if they do not have, or
do not want, support from a partner, friend or carer. Support could come from a nurse,
social worker, translator or volunteer (for example, an advocate) who can:
• help them to understand the resources provided
• encourage the person to take an active part in decision making
• reassure them that shared decision making will be supported by the healthcare professional
they see."
|
| Operationalization |
Free text. |
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Appointment actions 0 … 1
prsb03-dataelement-14074
|
|
|
| Id |
prsb03-dataelement-14074 (2021‑02‑17 23:54:32)
|
| Cardinality |
0 … 1 |
| Description |
A record of the actions taken to support shared decision making during the encounter. |
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Shared decision cluster 0 … 1
prsb03-dataelement-14095
|
|
|
| Id |
prsb03-dataelement-14095 (2021‑02‑21 15:14:29)
|
| Cardinality |
0 … 1 |
| Description |
A generic shared decision cluster. |
| Comment |
The following frameworks should be considered as alternative versions for recording
the core shared decision making discussion:
- Shared decision cluster
- Ask 3 questions model cluster
- BRA(I)N model cluster
- Three talk model cluster
To avoid duplication in the record only one of the above needs to be recorded.
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Decision dialogue (deliberation) 0 … 1
prsb03-dataelement-14099
|
|
|
| Id |
prsb03-dataelement-14099 (2021‑02‑21 16:43:09)
|
| Cardinality |
0 … 1 |
| Description |
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
|
| Comment |
The General Medical Council guidance on Decision making
(GMC, 2020) and consent states in section 10 that : "You must give patients the information they
want or need to make a decision. This will usually include: diagnosis and prognosis,
uncertainties about the diagnosis or prognosis, including options for further investigation,
options for treating or managing the condition, including the option to take no action,
the nature of each option, what would be involved, and the desired outcome, the potential
benefits, risks of harm, uncertainties about and likelihood of success for each option,
including the option to take no action."
The NICE Shared decision making guideline
(in development) states in section 1.2.9: "When offering tests, treatments or other healthcare services:
• openly discuss the risks, benefits and consequences of each option, making sure
the person knows this includes choosing no treatment, or no change to what they are
currently doing (the ‘option talk’ stage)."
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Establishing what matters to the person 0 … 1
prsb03-dataelement-14101
|
|
|
| Id |
prsb03-dataelement-14101 (2021‑02‑22 13:16:02)
|
| Cardinality |
0 … 1 |
| Description |
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.
|
| Relationship |
|
| Comment |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Agenda setting 0 … 1
prsb03-dataelement-14089
|
|
|
| Id |
prsb03-dataelement-14089 (2021‑02‑18 01:44:37)
|
| Cardinality |
0 … 1 |
| Description |
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.
|
| Comment |
The NICE guideline on Shared Decision Making (
in draft) states in section 1.2.6:
"Agree an ‘agenda’ at the start of each appointment to prioritise together what to
discuss. Say how long the appointment will last."
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Patient agenda 0 … 1
prsb03-dataelement-14091
|
|
|
| Id |
prsb03-dataelement-14091 (2021‑02‑18 01:58:28)
|
| Cardinality |
0 … 1 |
| Description |
A record of what the patient said was their agenda (talk topic(s)) for the appointment. |
| Comment |
This may have been elicited by encouraging the patient use the phrase 'My agenda for
today is...'
The NICE guideline on Shared Decision Making (
in draft) states in section 1.2.6:
"Agree an ‘agenda’ at the start of each appointment to prioritise together what to
discuss. Say how long the appointment will last."
|
| Operationalization |
Free text. |
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Clinician agenda 0 … 1
prsb03-dataelement-14090
|
|
|
| Id |
prsb03-dataelement-14090 (2021‑02‑18 01:51:20)
|
| Cardinality |
0 … 1 |
| Description |
A record of the clinician's stated agenda (talk topic(s)) for the appointment. |
| Comment |
This may have been communicated to the patient with phrases such as 'My agenda for
today is...'
The NICE Shared Decision Making guideline (in draft) states in section 1.2.6:
"Agree an ‘agenda’ at the start of each appointment to prioritise together what to
discuss. Say how long the appointment will last."
|
| Operationalization |
Free text. |
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Person goals, values, hopes, ideas, concerns, expectations 0 … 1
prsb03-dataelement-14102
|
|
|
| Id |
prsb03-dataelement-14102 (2021‑02‑22 13:16:02)
|
| Cardinality |
0 … 1 |
| Description |
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.
|
| Relationship |
|
| Operationalization |
Free text. |
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Person understanding of their condition or diagnosis 0 … 1
prsb03-dataelement-14304
|
|
|
| Id |
prsb03-dataelement-14304 (2021‑06‑13 19:03:06)
|
| Cardinality |
0 … 1 |
| Description |
A record of the person's understanding of their diagnosis (or possible diagnosis)
or condition.
|
| Operationalization |
Free text. |
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Options discussed 0 … *
prsb03-dataelement-14285
|
|
|
| Id |
prsb03-dataelement-14285 (2021‑06‑13 17:21:28)
|
| Cardinality |
0 … * |
| Description |
Record of the options discussed. Includes:
- Option entry
- Risks communicated about the option
- Benefits communicated about the option
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Option entry 0 … 1
prsb03-dataelement-14105
|
|
|
| Id |
prsb03-dataelement-14105 (2021‑02‑22 13:16:02)
|
| Cardinality |
0 … 1 |
| Description |
Record of the option discussed. |
| Relationship |
|
| Comment |
The General Medical Council (GMC) Decision Making and Consent guidance
(GMC, 2020) states that when discussing options for treating or managing a condition the clinician
involved must include the option to take no action:
"Doctors must try to find out what matters to patients so they can share relevant
information about the benefits and harms of proposed options and reasonable alternatives,
including the option to take no action (Principle 4)."
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Coded value 0 … 1
prsb03-dataelement-14106
|
|
|
| Id |
prsb03-dataelement-14106 (2021‑02‑22 13:16:02)
|
| Cardinality |
0 … 1 |
| Description |
Coded value of the option discussed. |
| Relationship |
|
| Operationalization |
SNOMED CT. |
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Free text 0 … 1
prsb03-dataelement-14107
|
|
|
| Id |
prsb03-dataelement-14107 (2021‑02‑22 13:16:02)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13925 (2021‑02‑03 10:18:29)
|
| Description |
Free text field to provide further detail or be used if no code is available. |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited once |
| |
This concept is inherited by concept
Free text in dataset prsb03-dataelement-14193
|
|
|
| Risks communication entry 0 … *
prsb03-dataelement-14111
|
|
|
| Id |
prsb03-dataelement-14111 (2021‑02‑22 13:16:02)
|
| Cardinality |
0 … * |
| Description |
Record of the risks discussed for each option. |
| Relationship |
|
| Comment |
The General Medical Council (GMC) Decision Making and Consent guidance
(GMC, 2020) states in section 21 that when discussing benefits and harms a clinician should include
the following: "Recognised risks of harm that [the clinician] believe[s] anyone in
the patient’s position would want to know... the effect of the patient’s individual
clinical circumstances on the probability of a benefit or harm occurring...risks of
harm and potential benefits that the patient would consider significant for any reason...any
risk of serious harm, however unlikely it is to occur...expected harms, including
common side effects and what to do if they occur."
"It wouldn’t be reasonable to share every possible risk of harm, potential complication
or side effect. Instead, you should tailor the discussion to each individual patient,
guided by what matters to them, and share information in a way they can understand."
(Section 22).
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Coded value 0 … 1
prsb03-dataelement-14113
|
|
|
| Id |
prsb03-dataelement-14113 (2021‑02‑22 13:16:02)
|
| Cardinality |
0 … 1 |
| Description |
Coded value of the risk discussed. |
| Relationship |
|
| Operationalization |
SNOMED CT. |
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Free text 0 … 1
prsb03-dataelement-14112
|
|
|
| Id |
prsb03-dataelement-14112 (2021‑02‑22 13:16:02)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13931 (2021‑02‑03 10:46:20)
|
| Description |
Free text field to provide further detail or be used if no code is available. |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Benefits entry 0 … *
prsb03-dataelement-14108
|
|
|
| Id |
prsb03-dataelement-14108 (2021‑02‑22 13:16:02)
|
| Cardinality |
0 … * |
| Description |
Record of the benefits discussed for each option. |
| Relationship |
|
| Comment |
The General Medical Council (GMC) Decision Making and Consent guidance
(GMC, 2020) states in section 21: "You must give patients clear, accurate and up-to-date information,
based on the best available evidence, about the potential benefits and risks of harm
of each option, including the option to take no action."
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Coded value 0 … 1
prsb03-dataelement-14109
|
|
|
| Id |
prsb03-dataelement-14109 (2021‑02‑22 13:16:02)
|
| Cardinality |
0 … 1 |
| Description |
Coded value of the benefit discussed. |
| Relationship |
|
| Operationalization |
SNOMED CT. |
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Free text 0 … 1
prsb03-dataelement-14110
|
|
|
| Id |
prsb03-dataelement-14110 (2021‑02‑22 13:16:02)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13928 (2021‑02‑03 10:35:02)
|
| Description |
Free text field to provide further detail or be used if no code is available. |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Decision support tool item entry 0 … 1
prsb03-dataelement-13955
|
|
|
| Id |
prsb03-dataelement-13955 (2021‑02‑03 13:43:54)
|
| Cardinality |
0 … 1 |
| Description |
Record of any decision support tools used. |
| Comment |
Examples of patient decision support tools include condition specific decision aids,
issue cards, decision boxes, fact boxes, question prompt lists (e.g. BRAN) and generic
communication frameworks. Where high-quality situation specific decision support tools
do not exist the clinician may need to interpret evidence sources developed for health
professionals. This may include decision support tools or materials brought by the
patient.
The General Medical Council (GMC) Decision making and consent guidance
(GMC, 2020) states in section 24: "You should consider using visual or other explanatory aids
to support patients to understand their personalised risk, taking account of their
individual clinical and personal circumstances, compared with population level risk."
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Decision support tool identifier 0 … 1
prsb03-dataelement-14092
|
|
|
| Id |
prsb03-dataelement-14092 (2021‑02‑18 02:21:49)
|
| Cardinality |
0 … 1 |
| Description |
Any alphanumeric identifier associated with the decision support tool (if applicable). |
| Operationalization |
Free text. |
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Decision support tool name 0 … 1
prsb03-dataelement-13956
|
|
|
| Id |
prsb03-dataelement-13956 (2021‑02‑03 13:53:18)
|
| Cardinality |
0 … 1 |
| Description |
The name of the decision support tool. |
| Operationalization |
Free text. |
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Decision support tool type 0 … 1
prsb03-dataelement-13957
|
|
|
| Id |
prsb03-dataelement-13957 (2021‑02‑03 13:59:31)
|
| Cardinality |
0 … 1 |
| Description |
The type of the decision support tool. |
| Comment |
Examples of patient decision support tools include condition specific decision aids,
issue cards, decision boxes, fact boxes, question prompt lists and generic communication
frameworks.
|
| Operationalization |
Free text |
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Decision support tool location 0 … 1
prsb03-dataelement-13958
|
|
|
| Id |
prsb03-dataelement-13958 (2021‑02‑03 14:14:39)
|
| Cardinality |
0 … 1 |
| Description |
The URL for the decision support tool. |
| Operationalization |
Free text. |
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Decision support tool MIME type 0 … 1
prsb03-dataelement-13959
|
|
|
| Id |
prsb03-dataelement-13959 (2021‑02‑03 14:32:12)
|
| Cardinality |
0 … 1 |
| Description |
MIME type of the document e.g. application, pdf, website. |
| Operationalization |
Free text. |
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Recording the decision 0 … 1
prsb03-dataelement-14114
|
|
|
| Id |
prsb03-dataelement-14114 (2021‑02‑22 13:16:02)
|
| Cardinality |
0 … 1 |
| Description |
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'.
|
| Relationship |
|
| Comment |
The NICE guideline on Shared Decision Making (in draft) states:
In section 1.2.13:
"Make a joint decision or plan about treatment or care and agree when this will be
reviewed (the ‘decision’ or ‘planning’ stage)."
In section 1.2.14:
"At the end of an appointment, state clearly what decisions have been made to make
sure the person agrees with and understands what has been decided, what happens next,
what the timescales are, and when it will be reviewed."
In section 1.2.15:
"When writing up the consultation, record any decisions made along with details of
what the person said was important to them in making those decisions."
|
| Operationalization |
Free text. |
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Decision entry 0 … 1
prsb03-dataelement-14191
|
|
|
| Id |
prsb03-dataelement-14191 (2021‑02‑24 15:10:35)
|
| Cardinality |
0 … 1 |
| Description |
Record of the decision. |
| Relationship |
|
| Comment |
GMC (DMC 50): "You should take a proportionate approach to the level of detail you record. Good
medical practice states that you must include the decisions made and actions agreed
- and who is making the decisions and agreeing the actions - in the patient's clinical
records. This includes the decision to take no action."
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Coded value 0 … 1
prsb03-dataelement-14192
|
|
|
| Id |
prsb03-dataelement-14192 (2021‑02‑24 15:12:01)
|
| Cardinality |
0 … 1 |
| Description |
Coded value of the decision agreed. |
| Relationship |
|
| Operationalization |
SNOMED CT. |
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Free text 0 … 1
prsb03-dataelement-14193
|
|
|
| Id |
prsb03-dataelement-14193 (2021‑02‑24 15:12:01)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-14107 (2021‑02‑22 13:16:02)
|
| Description |
Free text field to provide further detail or be used if no code is available. |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Planned review date/interval 0 … 1
prsb03-dataelement-14190
|
|
|
| Id |
prsb03-dataelement-14190 (2021‑02‑24 15:03:16)
|
| Cardinality |
0 … 1 |
| Description |
This is the date/interval when this information will next be reviewed. |
| Comment |
GMC (DMC 56): "Unless treatment or care begins immediately after a patient has given consent,
there will be opportunity for a decision to be reviewed."
GMC (DMC 57): "You should review a patient’s decision immediately before providing treatment or
care and, if treatment is ongoing, make sure there are clear arrangements
in place to review decisions regularly, allowing patients opportunity to ask questions
and discuss any concerns. You should also consider regularly reviewing a decision
to take no action."
GMC (DMC 58): "Reviewing a decision is particularly important: if you haven’t personally had a
discussion with the patient because they were initially seen by a colleague, if significant
time has passed since the decision was made, if the patient’s condition has changed,
if you have reason to believe the patient might have changed their mind, if any aspect
of the chosen treatment or care has changed, if new information has become available
about the potential benefits or risks of harm of any of the options that might make
the patient choose differently."
|
| Operationalization |
Date and time or free text. |
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Evaluating the decision 0 … 1
prsb03-dataelement-14228
|
|
|
| Id |
prsb03-dataelement-14228 (2021‑02‑26 00:41:18)
|
| Cardinality |
0 … 1 |
| Description |
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).
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Decision related values and preferences 0 … 1
prsb03-dataelement-14295
|
|
|
| Id |
prsb03-dataelement-14295 (2021‑06‑13 18:26:19)
|
| Cardinality |
0 … 1 |
| Description |
A record of the clinician and person preferences and values that are relevant to the
decision-made.
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Person decision related values and preferences 0 … 1
prsb03-dataelement-14297
|
|
|
| Id |
prsb03-dataelement-14297 (2021‑06‑13 18:33:18)
|
| Cardinality |
0 … 1 |
| Description |
A record of the person's values and preferences related to the decision-made. |
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Decision made person preference indicator 0 … 1
prsb03-dataelement-14300
|
|
|
| Id |
prsb03-dataelement-14300 (2021‑06‑13 18:40:42)
|
| Cardinality |
0 … 1 |
| Description |
An indicator of whether the decision made was the person's first preference. (Yes
or No)
|
| Operationalization |
Code. (Yes or No) |
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Reason given to person for preference not offered 0 … 1
prsb03-dataelement-14299
|
|
|
| Id |
prsb03-dataelement-14299 (2021‑06‑13 18:39:37)
|
| Cardinality |
0 … 1 |
| Description |
A description of the reasons for why a person's first preference could not be accommodated. |
| Operationalization |
Free text. |
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Person preferred option 0 … 1
prsb03-dataelement-14298
|
|
|
| Id |
prsb03-dataelement-14298 (2021‑06‑13 18:38:07)
|
| Cardinality |
0 … 1 |
| Description |
A record of the person's preferred option. |
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Coded value 0 … 1
prsb03-dataelement-14307
|
|
|
| Id |
prsb03-dataelement-14307 (2021‑06‑13 21:39:19)
|
| Cardinality |
0 … 1 |
| Description |
The coded value for the person's preferred option. |
| Operationalization |
SNOMED CT |
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Free text 0 … 1
prsb03-dataelement-14306
|
|
|
| Id |
prsb03-dataelement-14306 (2021‑06‑13 21:36:42)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13886 (2021‑02‑01 18:42:31)
|
| Description |
Free text field to provide further detail or be used if no code is available. |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Person reasons given for preference 0 … 1
prsb03-dataelement-14296
|
|
|
| Id |
prsb03-dataelement-14296 (2021‑06‑13 18:29:52)
|
| Cardinality |
0 … 1 |
| Description |
An account of the reason(s) the person has given for their preference(s). |
| Operationalization |
Free text. |
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Clinician decision related values and preferences 0 … 1
prsb03-dataelement-14301
|
|
|
| Id |
prsb03-dataelement-14301 (2021‑06‑13 18:42:00)
|
| Cardinality |
0 … 1 |
| Description |
A record of the clinician's relevant values and preferences that were disclosed during
the conversation.
|
| Operationalization |
Free text. |
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Clinician agreement with person decision indicator 0 … 1
prsb03-dataelement-14303
|
|
|
| Id |
prsb03-dataelement-14303 (2021‑06‑13 18:45:08)
|
| Cardinality |
0 … 1 |
| Description |
An indicator of whether the clinician agreed with the decision made. (Yes or No). |
| Operationalization |
Code. (Yes or No). |
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Reason given to person for disagreement 0 … 1
prsb03-dataelement-14302
|
|
|
| Id |
prsb03-dataelement-14302 (2021‑06‑13 18:44:30)
|
| Cardinality |
0 … 1 |
| Description |
Reason(s) given to the person for the clinician's recommendation/preference(s) where
they disagreed with the decision made.
|
| Operationalization |
Free text. |
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Decision satisfaction or regret 0 … 1
prsb03-dataelement-14231
|
|
|
| Id |
prsb03-dataelement-14231 (2021‑02‑26 01:20:26)
|
| Cardinality |
0 … 1 |
| Description |
A record of clinician and patient satisfaction (or regret) relating to the decision. |
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Patient decision satisfaction 0 … 1
prsb03-dataelement-14232
|
|
|
| Id |
prsb03-dataelement-14232 (2021‑02‑26 01:23:52)
|
| Cardinality |
0 … 1 |
| Description |
A record of the person's level of satisfaction (or regret) with the decision made
and the reasons for this.
|
| Operationalization |
Free text. |
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Clinician decision satisfaction 0 … 1
prsb03-dataelement-14230
|
|
|
| Id |
prsb03-dataelement-14230 (2021‑02‑26 01:15:05)
|
| Cardinality |
0 … 1 |
| Description |
A record of whether the clinician agreed with the patient's chosen option and the
reasons for this.
|
| Operationalization |
Free text. |
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Information withheld or sharing delayed 0 … 1
prsb03-dataelement-14286
|
|
|
| Id |
prsb03-dataelement-14286 (2021‑06‑13 17:55:21)
|
| Cardinality |
0 … 1 |
| Description |
A structured record of the information that will be withheld or the sharing of delayed. |
| Comment |
The General Medical Council (GMC) Decision Making and Consent guidance
(GMC, 2020)
tells of exceptional circumstances where sharing of certain relevant information with
the patient withheld or delayed. Where it is delayed the guidance instructs practitioners
to record ‘the information [they] still need to share, [their] reasons for not sharing
it now, and when it can be shared.’ The guidance also clarifies that ‘in [the] very
exceptional circumstances’ where information is withheld because it would cause the
patient ‘very serious harm’ legal advice should be sought.
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Information withheld from person 0 … 1
prsb03-dataelement-14288
|
|
|
| Id |
prsb03-dataelement-14288 (2021‑06‑13 18:04:33)
|
| Cardinality |
0 … 1 |
| Description |
A record of the information withheld from the person. |
| Operationalization |
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.
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Information withheld indicator 0 … 1
prsb03-dataelement-14305
|
|
|
| Id |
prsb03-dataelement-14305 (2021‑06‑13 21:08:56)
|
| Cardinality |
0 … 1 |
| Description |
An indicator of whether information was withheld from the person. Yes or No. |
| Operationalization |
Code: Yes or No. |
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
 Information withheld indicator 0 … 1
prsb03-dataelement-14287
|
|
|
| Id |
prsb03-dataelement-14287 (2021‑06‑13 18:01:24)
|
| Cardinality |
0 … 1 |
| Description |
An indicator to record that information was withheld from the person. (Yes or No) |
| Operationalization |
Code (Y/N)
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Reason information withheld 0 … 1
prsb03-dataelement-14289
|
|
|
| Id |
prsb03-dataelement-14289 (2021‑06‑13 18:06:06)
|
| Cardinality |
0 … 1 |
| Description |
A description of the reason the information has been withheld from the person. |
| Operationalization |
Free text. |
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Legal advice sought 0 … 1
prsb03-dataelement-14292
|
|
|
| Id |
prsb03-dataelement-14292 (2021‑06‑13 18:13:55)
|
| Cardinality |
0 … 1 |
| Description |
Relevant details of any legal advice sought where information has been withheld from
the person.
|
| Operationalization |
Free text |
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Information sharing delayed 0 … 1
prsb03-dataelement-14290
|
|
|
| Id |
prsb03-dataelement-14290 (2021‑06‑13 18:08:09)
|
| Cardinality |
0 … 1 |
| Description |
Details of where information sharing with the person has been delayed. |
| Comment |
The General Medical Council (GMC) Decision Making and Consent guidance
(GMC, 2020)
tells of exceptional circumstances where sharing of certain relevant information with
the patient withheld or delayed. Where information sharing is delayed the guidance
instructs practitioners to record ‘the information [they] still need to share, [their]
reasons for not sharing it now, and when it can be shared.’
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Information still to share 0 … 1
prsb03-dataelement-14294
|
|
|
| Id |
prsb03-dataelement-14294 (2021‑06‑13 18:16:32)
|
| Cardinality |
0 … 1 |
| Description |
Details of the information that still needs to be shared. |
| Operationalization |
Free text. |
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Reasons for not sharing the information now 0 … 1
prsb03-dataelement-14293
|
|
|
| Id |
prsb03-dataelement-14293 (2021‑06‑13 18:15:37)
|
| Cardinality |
0 … 1 |
| Description |
An account of the professional's reason(s) for not sharing the information with the
person during the encounter
|
| Operationalization |
Free text. |
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| When the information can be shared 0 … 1
prsb03-dataelement-14291
|
|
|
| Id |
prsb03-dataelement-14291 (2021‑06‑13 18:11:38)
|
| Cardinality |
0 … 1 |
| Description |
A explanation of what needs to happens so that the information can be shared. |
| Operationalization |
Free text. |
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Performing professional 0 … 1
prsb03-dataelement-14115
|
|
|
| Id |
prsb03-dataelement-14115 (2021‑02‑22 13:16:02)
|
| Cardinality |
0 … 1 |
| Description |
The professional who conducted the shared decision making conversation. |
| Relationship |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Organisation 0 … 1
prsb03-dataelement-14116
|
|
|
| Id |
prsb03-dataelement-14116 (2021‑02‑22 13:16:02)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13934 (2021‑02‑03 11:20:19)
|
| Description |
The name of the organisation the professional works for. |
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited once |
| |
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-14720
|
|
|
| Name 0 … 1
prsb03-dataelement-14117
|
|
|
| Id |
prsb03-dataelement-14117 (2021‑02‑22 13:16:02)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13935 (2021‑02‑03 11:20:19)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited once |
| |
This concept is inherited by concept
Name in dataset prsb03-dataelement-14721
|
|
|
| Role 0 … 1
prsb03-dataelement-14118
|
|
|
| Id |
prsb03-dataelement-14118 (2021‑02‑22 13:16:02)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13936 (2021‑02‑03 11:20:19)
|
| Description |
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etc.
|
| Rationale |
Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set:-
SDSjobrolename
|
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited once |
| |
This concept is inherited by concept
Role in dataset prsb03-dataelement-14722
|
|
|
| Grade 0 … 1
prsb03-dataelement-14119
|
|
|
| Id |
prsb03-dataelement-14119 (2021‑02‑22 13:16:02)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13937 (2021‑02‑03 11:20:19)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited once |
| |
This concept is inherited by concept
Grade in dataset prsb03-dataelement-14723
|
|
|
| Specialty 0 … 1
prsb03-dataelement-14120
|
|
|
| Id |
prsb03-dataelement-14120 (2021‑02‑22 13:16:02)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13938 (2021‑02‑03 11:20:19)
|
| Description |
The specialty of the professional e.g. physiotherapy, oncology, mental health etc. |
| Rationale |
PractitionerRole.speciality |
| Operationalization |
NHS data dictionary :-
Care professional main speciality code
|
| Value Domain |
|
| Property |
| min length |
max length |
| 3 |
3 |
|
| Used by
|
one transaction, 0 templates, inherited once |
| |
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-14724
|
|
|
| Professional identifier 0 … 1
prsb03-dataelement-14121
|
|
|
| Id |
prsb03-dataelement-14121 (2021‑02‑22 13:16:02)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13939 (2021‑02‑03 11:20:19)
|
| Description |
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.
|
| Rationale |
Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier
(for local role identifiers)
|
| Operationalization |
NHS data dictionary :-
Professional registration entry identifier
|
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited once |
| |
|
|
|
| Organisation 0 … 1
prsb03-dataelement-14122
|
|
|
| Id |
prsb03-dataelement-14122 (2021‑02‑22 13:16:02)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13940 (2021‑02‑03 11:20:19)
|
| Description |
The name of the organisation the professional works for. |
| Used by
|
one transaction, 0 templates, inherited once |
| |
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-14726
|
|
|
| Coded value 0 … 1
prsb03-dataelement-14123
|
|
|
| Id |
prsb03-dataelement-14123 (2021‑02‑22 13:16:02)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13941 (2021‑02‑03 11:20:19)
|
| Description |
The coded value for the organisation. |
| Operationalization |
NHS data dictionary :-
Organisation identifier
|
| Value Domain |
|
| Property |
| min length |
max length |
| 3 |
8 |
|
| Used by
|
one transaction, 0 templates, inherited once |
| |
This concept is inherited by concept
Coded value in dataset prsb03-dataelement-14727
|
|
|
| Free text 0 … 1
prsb03-dataelement-14124
|
|
|
| Id |
prsb03-dataelement-14124 (2021‑02‑22 13:16:02)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13942 (2021‑02‑03 11:20:19)
|
| Description |
Free text field to provide further detail or be used if no code is available. |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited once |
| |
This concept is inherited by concept
Free text in dataset prsb03-dataelement-14728
|
|
|
| Contact details 0 … 1
prsb03-dataelement-14125
|
|
|
| Id |
prsb03-dataelement-14125 (2021‑02‑22 13:16:02)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13943 (2021‑02‑03 11:20:19)
|
| Description |
Contact details of the professional. |
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telecom
|
| Operationalization |
NHS data dictionary :-
UK telephone number
|
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited once |
| |
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-14729
|
|
|
| Person completing record 0 … 1
prsb03-dataelement-14126
|
|
|
| Id |
prsb03-dataelement-14126 (2021‑02‑22 13:16:02)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13944 (2021‑02‑03 11:48:41)
|
| Description |
Details of the person completing the record. |
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Name 0 … 1
prsb03-dataelement-14127
|
|
|
| Id |
prsb03-dataelement-14127 (2021‑02‑22 13:16:02)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13945 (2021‑02‑03 11:49:43)
|
| Description |
The name of the person completing the record. |
| Rationale |
Composition.author.Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Role 0 … 1
prsb03-dataelement-14128
|
|
|
| Id |
prsb03-dataelement-14128 (2021‑02‑22 13:16:02)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13946 (2021‑02‑03 11:49:43)
|
| Description |
The organisational role of the person completing the record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSJobRoleName
|
| Value Domain |
|
| Property |
| min length |
max length |
| 5 |
5 |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Grade 0 … 1
prsb03-dataelement-14129
|
|
|
| Id |
prsb03-dataelement-14129 (2021‑02‑22 13:16:02)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13947 (2021‑02‑03 11:49:43)
|
| Description |
The grade of the person completing the record. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Specialty 0 … 1
prsb03-dataelement-14130
|
|
|
| Id |
prsb03-dataelement-14130 (2021‑02‑22 13:16:02)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13948 (2021‑02‑03 11:49:43)
|
| Description |
The main specialty of the person completing the record. |
| FHIR |
PractitionerRole.specialty |
|
| Rationale |
PractitionerRole.specialty |
| Operationalization |
NHS data dictionary :-
Activity treatment function code
|
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Organisation 0 … 1
prsb03-dataelement-14131
|
|
|
| Id |
prsb03-dataelement-14131 (2021‑02‑22 13:16:02)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13949 (2021‑02‑03 11:49:43)
|
| Description |
The organisation the person completing the record works for. |
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Coded value 0 … 1
prsb03-dataelement-14132
|
|
|
|
|
| Free text 0 … 1
prsb03-dataelement-14133
|
|
|
| Id |
prsb03-dataelement-14133 (2021‑02‑22 13:16:02)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13951 (2021‑02‑03 11:49:43)
|
| Description |
Free text field to provide further detail or be used if no code is available. |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Professional identifier 0 … 1
prsb03-dataelement-14134
|
|
|
| Id |
prsb03-dataelement-14134 (2021‑02‑22 13:16:02)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13952 (2021‑02‑03 11:49:43)
|
| Description |
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.
|
| FHIR |
PractitionerRole.Practitioner.identifier (local) Practitioner.identifer (professional) |
|
| Rationale |
Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier
(for local role identifiers)
|
| Operationalization |
NHS data dictionary :-
Professional registration entry identifier
|
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Date completed 0 … 1
prsb03-dataelement-14135
|
|
|
| Id |
prsb03-dataelement-14135 (2021‑02‑22 13:16:02)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13953 (2021‑02‑03 11:49:43)
|
| Description |
The date and time the record was completed. |
| Rationale |
Composition.date |
| Operationalization |
Date and time. |
| Value Domain |
|
| Property |
| Timestamp precision |
| at least day, month and year, hour and minute |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Contact details 0 … 1
prsb03-dataelement-14136
|
|
|
| Id |
prsb03-dataelement-14136 (2021‑02‑22 13:16:02)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13954 (2021‑02‑03 11:49:43)
|
| Description |
Contact details of the person completing the record (e.g. telephone number, email
address etc.).
|
| FHIR |
PractitionerRole.telecom |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telecom
|
| Operationalization |
NHS data dictionary :-
UK telephone number
|
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Ask 3 questions model cluster 0 … 1
prsb03-dataelement-14019
|
|
|
| Id |
prsb03-dataelement-14019 (2021‑02‑15 12:25:33)
|
| Cardinality |
0 … 1 |
| Description |
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?
|
| Comment |
Ask 3 questions is the patient focused part of the national Shared Decision Making programme. It
has been adapted with permission for use in the NHS by the
Advancing Quality Alliance (AQuA) from the Making Good Decisions in Collaboration (
MAGIC) improvement programme. AQuA has developed films, posters and other materials for
its Ask 3 questions campaign to be seen by patients in advance of clinical encounters,
where a decision may need to be made.
The framework is based on a set of questions originally tested by
Shepherd
et al. 2011
in a cross over trial. The questions tested were:
What are my options? What are the benefits and harms? How likely are these?
In the study, use of these questions was associated with improved scores in the Assessing
Communication about Evidence and Patient Preferences (ACEPP) and OPTION (observing
patient involvement) scales.
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Ask 3 questions item entry 1 0 … 1
prsb03-dataelement-14020
|
|
|
| Id |
prsb03-dataelement-14020 (2021‑02‑15 16:13:27)
|
| Cardinality |
0 … 1 |
| Description |
A record of what was discussed following the patient asking the question 'What are
my options?' (Ask 3 questions framework).
|
| Operationalization |
Free text. |
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Ask 3 questions item entry 2 0 … 1
prsb03-dataelement-14021
|
|
|
| Id |
prsb03-dataelement-14021 (2021‑02‑15 16:31:13)
|
| Cardinality |
0 … 1 |
| Description |
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).
|
| Operationalization |
Free text. |
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Ask 3 questions item entry 3 0 … 1
prsb03-dataelement-14022
|
|
|
| Id |
prsb03-dataelement-14022 (2021‑02‑15 16:38:01)
|
| Cardinality |
0 … 1 |
| Description |
A record of what was discussed following the patient asking the question ' What are
my options?' (Ask 3 questions framework).
|
| Operationalization |
Free text. |
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Performing professional 0 … 1
prsb03-dataelement-14024
|
|
|
| Id |
prsb03-dataelement-14024 (2021‑02‑15 17:37:30)
|
| Cardinality |
0 … 1 |
| Description |
The professional who conducted the shared decision making conversation (Ask 3 questions
framework).
|
| Relationship |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Organisation 0 … 1
prsb03-dataelement-14045
|
|
|
| Id |
prsb03-dataelement-14045 (2021‑02‑15 17:40:29)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13902 (2021‑02‑02 18:16:27)
|
| Description |
The name of the organisation the professional works for. |
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Name 0 … 1
prsb03-dataelement-14046
|
|
|
| Id |
prsb03-dataelement-14046 (2021‑02‑15 17:40:29)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13897 (2021‑02‑01 20:13:26)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Role 0 … 1
prsb03-dataelement-14047
|
|
|
| Id |
prsb03-dataelement-14047 (2021‑02‑15 17:40:29)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13898 (2021‑02‑01 20:17:22)
|
| Description |
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etc.
|
| Rationale |
Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set:-
SDSjobrolename
|
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Grade 0 … 1
prsb03-dataelement-14048
|
|
|
| Id |
prsb03-dataelement-14048 (2021‑02‑15 17:40:29)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13899 (2021‑02‑01 20:23:02)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Specialty 0 … 1
prsb03-dataelement-14049
|
|
|
| Id |
prsb03-dataelement-14049 (2021‑02‑15 17:40:29)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13900 (2021‑02‑01 20:28:38)
|
| Description |
The specialty of the professional e.g. physiotherapy, oncology, mental health etc. |
| Rationale |
PractitionerRole.speciality |
| Operationalization |
NHS data dictionary :-
Care professional main speciality code
|
| Value Domain |
|
| Property |
| min length |
max length |
| 3 |
3 |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Professional identifier 0 … 1
prsb03-dataelement-14050
|
|
|
| Id |
prsb03-dataelement-14050 (2021‑02‑15 17:40:29)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13901 (2021‑02‑02 18:12:20)
|
| Description |
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.
|
| Rationale |
Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier
(for local role identifiers)
|
| Operationalization |
NHS data dictionary :-
Professional registration entry identifier
|
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Organisation 0 … 1
prsb03-dataelement-14051
|
|
|
| Id |
prsb03-dataelement-14051 (2021‑02‑15 17:40:29)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13903 (2021‑02‑02 21:35:36)
|
| Description |
The name of the organisation the professional works for. |
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Coded value 0 … 1
prsb03-dataelement-14052
|
|
|
| Id |
prsb03-dataelement-14052 (2021‑02‑15 17:40:29)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13904 (2021‑02‑02 21:41:22)
|
| Description |
The coded value for the organisation. |
| Operationalization |
NHS data dictionary :-
Organisation identifier
|
| Value Domain |
|
| Property |
| min length |
max length |
| 3 |
8 |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Free text 0 … 1
prsb03-dataelement-14053
|
|
|
| Id |
prsb03-dataelement-14053 (2021‑02‑15 17:40:29)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13905 (2021‑02‑02 21:45:00)
|
| Description |
Free text field to provide further detail or be used if no code is available. |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Contact details 0 … 1
prsb03-dataelement-14054
|
|
|
| Id |
prsb03-dataelement-14054 (2021‑02‑15 17:40:29)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13906 (2021‑02‑02 21:51:13)
|
| Description |
Contact details of the professional. |
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telecom
|
| Operationalization |
NHS data dictionary :-
UK telephone number
|
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Person completing record 0 … 1
prsb03-dataelement-14055
|
|
|
| Id |
prsb03-dataelement-14055 (2021‑02‑17 11:34:44)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13907 (2021‑02‑02 22:27:51)
|
| Description |
Details of the person completing the record. |
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Name 0 … 1
prsb03-dataelement-14056
|
|
|
| Id |
prsb03-dataelement-14056 (2021‑02‑17 11:36:42)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13908 (2021‑02‑02 22:35:30)
|
| Description |
The name of the person completing the record. |
| Rationale |
Composition.author.Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Role 0 … 1
prsb03-dataelement-14057
|
|
|
| Id |
prsb03-dataelement-14057 (2021‑02‑17 11:36:42)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13909 (2021‑02‑02 22:37:50)
|
| Description |
The organisational role of the person completing the record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSJobRoleName
|
| Value Domain |
|
| Property |
| min length |
max length |
| 5 |
5 |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Grade 0 … 1
prsb03-dataelement-14058
|
|
|
| Id |
prsb03-dataelement-14058 (2021‑02‑17 11:36:42)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13910 (2021‑02‑02 22:42:50)
|
| Description |
The grade of the person completing the record. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Specialty 0 … 1
prsb03-dataelement-14059
|
|
|
| Id |
prsb03-dataelement-14059 (2021‑02‑17 11:36:42)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13911 (2021‑02‑02 22:47:46)
|
| Description |
The main specialty of the person completing the record. |
| FHIR |
PractitionerRole.specialty |
|
| Rationale |
PractitionerRole.specialty |
| Operationalization |
NHS data dictionary :-
Activity treatment function code
|
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Organisation 0 … 1
prsb03-dataelement-14060
|
|
|
| Id |
prsb03-dataelement-14060 (2021‑02‑17 11:36:42)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13912 (2021‑02‑02 22:55:15)
|
| Description |
The organisation the person completing the record works for. |
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Coded value 0 … 1
prsb03-dataelement-14061
|
|
|
|
|
| Free text 0 … 1
prsb03-dataelement-14062
|
|
|
| Id |
prsb03-dataelement-14062 (2021‑02‑17 11:36:42)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13914 (2021‑02‑02 23:02:16)
|
| Description |
Free text field to provide further detail or be used if no code is available. |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Professional identifier 0 … 1
prsb03-dataelement-14063
|
|
|
| Id |
prsb03-dataelement-14063 (2021‑02‑17 11:36:42)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13915 (2021‑02‑02 23:06:19)
|
| Description |
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.
|
| FHIR |
PractitionerRole.Practitioner.identifier (local) Practitioner.identifer (professional) |
|
| Rationale |
Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier
(for local role identifiers)
|
| Operationalization |
NHS data dictionary :-
Professional registration entry identifier
|
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Date completed 0 … 1
prsb03-dataelement-14064
|
|
|
| Id |
prsb03-dataelement-14064 (2021‑02‑17 11:36:42)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13916 (2021‑02‑02 23:12:04)
|
| Description |
The date and time the record was completed. |
| Rationale |
Composition.date |
| Operationalization |
Date and time. |
| Value Domain |
|
| Property |
| Timestamp precision |
| at least day, month and year, hour and minute |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Contact details 0 … 1
prsb03-dataelement-14065
|
|
|
| Id |
prsb03-dataelement-14065 (2021‑02‑17 11:36:42)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13917 (2021‑02‑02 23:16:07)
|
| Description |
Contact details of the person completing the record (e.g. telephone number, email
address etc.).
|
| FHIR |
PractitionerRole.telecom |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telecom
|
| Operationalization |
NHS data dictionary :-
UK telephone number
|
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| BRA(I)N model Cluster 0 … 1
prsb03-dataelement-13879
|
|
|
| Id |
prsb03-dataelement-13879 (2021‑02‑01 16:24:40)
|
| Cardinality |
0 … 1 |
| Description |
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)
|
| Comment |
The acronym BRAN is a decision support tool endorsed by the Academy of Medical Royal
Colleges (AoMRC) for the purpose of structuring shared decision making conversations
(BMJ, 2019).
The Centre for Collaboration, Motivation, and Innovation has developed a BRAN alternative
called BRAIN
(CCMI, 2015).
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Benefits entry 0 … *
prsb03-dataelement-13880
|
|
|
| Id |
prsb03-dataelement-13880 (2021‑02‑01 16:40:31)
|
| Cardinality |
0 … * |
| Description |
A record of the benefits discussed as part of the shared decision making conversation
(BRAN or BRAIN framework).
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Coded value 0 … 1
prsb03-dataelement-13885
|
|
|
| Id |
prsb03-dataelement-13885 (2021‑02‑01 18:38:52)
|
| Cardinality |
0 … 1 |
| Description |
Coded value of the benefits discussed. |
| Operationalization |
SNOMED CT. |
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Free text 0 … 1
prsb03-dataelement-13886
|
|
|
| Id |
prsb03-dataelement-13886 (2021‑02‑01 18:42:31)
|
| Cardinality |
0 … 1 |
| Description |
Free text field to provide further detail or be used if no code is available. |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited 17 times |
| |
This concept is inherited by concept
Free text in dataset prsb03-dataelement-16370
This concept is inherited by concept
Free text in dataset prsb03-dataelement-16493
This concept is inherited by concept
Free text in dataset prsb03-dataelement-16594
This concept is inherited by concept
Free text in dataset prsb03-dataelement-16596
This concept is inherited by concept
Free text in dataset prsb03-dataelement-14069
This concept is inherited by concept
Free text in dataset prsb03-dataelement-14072
This concept is inherited by concept
Free text in dataset prsb03-dataelement-14306
This concept is inherited by concept
Free text in dataset prsb03-dataelement-13888
This concept is inherited by concept
Free text in dataset prsb03-dataelement-13890
This concept is inherited by concept
Free text in dataset prsb03-dataelement-13893
This concept is inherited by concept
Free text in dataset prsb03-dataelement-13905
This concept is inherited by concept
Free text in dataset prsb03-dataelement-13914
This concept is inherited by concept
Free text in dataset prsb03-dataelement-13925
This concept is inherited by concept
Free text in dataset prsb03-dataelement-13928
This concept is inherited by concept
Free text in dataset prsb03-dataelement-13931
This concept is inherited by concept
Free text in dataset prsb03-dataelement-14199
This concept is inherited by concept
Free text in dataset prsb03-dataelement-14202
|
|
|
| Risks entry 0 … *
prsb03-dataelement-13881
|
|
|
| Id |
prsb03-dataelement-13881 (2021‑02‑01 16:44:09)
|
| Cardinality |
0 … * |
| Description |
A record of the risks discussed as part of the shared decision making conversation
(BRAN or BRAIN framework).
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Coded value 0 … 1
prsb03-dataelement-13887
|
|
|
| Id |
prsb03-dataelement-13887 (2021‑02‑01 18:47:38)
|
| Cardinality |
0 … 1 |
| Description |
Coded value of the risks discussed. |
| Operationalization |
SNOMED CT. |
| Value Domain |
|
| Choice list |
| Concept List |
| Concept |
Description |
|
|
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Free text 0 … 1
prsb03-dataelement-13888
|
|
|
| Id |
prsb03-dataelement-13888 (2021‑02‑01 18:50:44)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13886 (2021‑02‑01 18:42:31)
|
| Description |
Free text field to provide further detail or be used if no code is available. |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Alternatives entry 0 … *
prsb03-dataelement-13882
|
|
|
| Id |
prsb03-dataelement-13882 (2021‑02‑01 16:47:00)
|
| Cardinality |
0 … * |
| Description |
A record of the alternatives discussed as part of the shared decision making conversation
(BRAN or BRAIN framework).
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Coded value 0 … 1
prsb03-dataelement-13889
|
|
|
| Id |
prsb03-dataelement-13889 (2021‑02‑01 18:55:16)
|
| Cardinality |
0 … 1 |
| Description |
Coded value of the alternatives discussed. |
| Relationship |
|
| Operationalization |
SNOMED CT. |
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Free text 0 … 1
prsb03-dataelement-13890
|
|
|
| Id |
prsb03-dataelement-13890 (2021‑02‑01 18:59:37)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13886 (2021‑02‑01 18:42:31)
|
| Description |
Free text field to provide further detail or be used if no code is available. |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Intuition entry 0 … 1
prsb03-dataelement-13891
|
|
|
| Id |
prsb03-dataelement-13891 (2021‑02‑01 19:10:42)
|
| Cardinality |
0 … 1 |
| Description |
A record of the person's intuition (BRAIN framework). |
| Comment |
The Centre for Collaboration, Motivation, and Innovation has developed a BRAN alternative
called BRAIN
(CCMI, 2015). This model involves the patient first asking the following questions:
What is the decision I need to make?
How much time do I have to make this decision?
Who is involved in making this decision?
What are my values that affect this decision?
The BRAIN mnemonic covers the following:
B = Benefits
R = Risks
A = Alternatives
I = Intuition
N = Next steps (as opposed to 'doing Nothing' in BRAN)
At the intuition step the patient asks the following question:
What do I feel and think about these options? The outcome should be entered into the
record here.
|
| Operationalization |
Free text. |
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Nothing entry 0 … 1
prsb03-dataelement-13884
|
|
|
| Id |
prsb03-dataelement-13884 (2021‑02‑01 18:34:45)
|
| Cardinality |
0 … 1 |
| Description |
An indicator showing whether the option to do nothing was discussed as part of the
shared decision making conversation (BRAN framework).
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Coded value 0 … 1
prsb03-dataelement-13892
|
|
|
| Id |
prsb03-dataelement-13892 (2021‑02‑01 19:16:02)
|
| Cardinality |
0 … 1 |
| Description |
Coded value to indicate whether the option to do nothing was discussed. |
| Operationalization |
Y = yes ; N = no |
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Free text 0 … 1
prsb03-dataelement-13893
|
|
|
| Id |
prsb03-dataelement-13893 (2021‑02‑01 19:21:14)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13886 (2021‑02‑01 18:42:31)
|
| Description |
Free text field to provide further detail or be used if no code is available. |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Next steps entry 0 … 1
prsb03-dataelement-13894
|
|
|
| Id |
prsb03-dataelement-13894 (2021‑02‑01 19:23:55)
|
| Cardinality |
0 … 1 |
| Description |
A record of the next steps considered (BRAIN framework). |
| Comment |
The Centre for Collaboration, Motivation, and Innovation has developed a BRAN alternative
called BRAIN:
B = Benefits
R = Risks
A = Alternatives
I = Intuition
N = Next steps (as opposed to 'doing Nothing' in BRAN)
Examples of questions that the patient may be encouraged to ask at the next steps
stage include
(CCMI,2015):
Do I need to talk to my family?
Do I need more time to think my decision through?
Do I want more information?
Would I like to wait on treatment?
Do I want a second opinion?
What would I like to do?
|
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Decision entry 0 … 1
prsb03-dataelement-13895
|
|
|
| Id |
prsb03-dataelement-13895 (2021‑02‑01 19:35:49)
|
| Cardinality |
0 … 1 |
| Description |
A record of the decision made (BRAN or BRAIN framework). |
| Comment |
The General Medical Council (GMC) Decision making and consent guidance
(GMC, 2020) states: "You should take a proportionate approach to the level of detail you record.
Good medical practice states that you must include the decisions made and actions
agreed - and who is making the decisions and agreeing the actions - in the patient's
clinical records. This includes decisions to take no action."
|
| Operationalization |
Free text. |
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Performing professional 0 … 1
prsb03-dataelement-13896
|
|
|
| Id |
prsb03-dataelement-13896 (2021‑02‑01 19:50:38)
|
| Cardinality |
0 … 1 |
| Description |
The professional who conducted the shared decision making conversation (BRAN or BRAIN
framework).
|
| Relationship |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Name 0 … 1
prsb03-dataelement-13897
|
|
|
| Id |
prsb03-dataelement-13897 (2021‑02‑01 20:13:26)
|
| Cardinality |
0 … 1 |
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited 4 times |
| |
This concept is inherited by concept
Name in dataset prsb03-dataelement-14046
This concept is inherited by concept
Name in dataset prsb03-dataelement-13935
This concept is inherited by concept
Name in dataset prsb03-dataelement-14701
This concept is inherited by concept
Name in dataset prsb03-dataelement-14664
|
|
|
| Role 0 … 1
prsb03-dataelement-13898
|
|
|
| Id |
prsb03-dataelement-13898 (2021‑02‑01 20:17:22)
|
| Cardinality |
0 … 1 |
| Description |
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etc.
|
| Rationale |
Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set:-
SDSjobrolename
|
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 4 times |
| |
This concept is inherited by concept
Role in dataset prsb03-dataelement-14047
This concept is inherited by concept
Role in dataset prsb03-dataelement-13936
This concept is inherited by concept
Role in dataset prsb03-dataelement-14702
This concept is inherited by concept
Role in dataset prsb03-dataelement-14665
|
|
|
| Grade 0 … 1
prsb03-dataelement-13899
|
|
|
| Id |
prsb03-dataelement-13899 (2021‑02‑01 20:23:02)
|
| Cardinality |
0 … 1 |
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited 4 times |
| |
This concept is inherited by concept
Grade in dataset prsb03-dataelement-14048
This concept is inherited by concept
Grade in dataset prsb03-dataelement-13937
This concept is inherited by concept
Grade in dataset prsb03-dataelement-14703
This concept is inherited by concept
Grade in dataset prsb03-dataelement-14666
|
|
|
| Specialty 0 … 1
prsb03-dataelement-13900
|
|
|
| Id |
prsb03-dataelement-13900 (2021‑02‑01 20:28:38)
|
| Cardinality |
0 … 1 |
| Description |
The specialty of the professional e.g. physiotherapy, oncology, mental health etc. |
| Rationale |
PractitionerRole.speciality |
| Operationalization |
NHS data dictionary :-
Care professional main speciality code
|
| Value Domain |
|
| Property |
| min length |
max length |
| 3 |
3 |
|
| Used by
|
one transaction, 0 templates, inherited 4 times |
| |
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-14049
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-13938
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-14704
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-14667
|
|
|
| Professional identifier 0 … 1
prsb03-dataelement-13901
|
|
|
| Id |
prsb03-dataelement-13901 (2021‑02‑02 18:12:20)
|
| Cardinality |
0 … 1 |
| Description |
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.
|
| Rationale |
Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier
(for local role identifiers)
|
| Operationalization |
NHS data dictionary :-
Professional registration entry identifier
|
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited 4 times |
| |
|
|
|
| Organisation 0 … 1
prsb03-dataelement-13903
|
|
|
| Id |
prsb03-dataelement-13903 (2021‑02‑02 21:35:36)
|
| Cardinality |
0 … 1 |
| Description |
The name of the organisation the professional works for. |
| Used by
|
one transaction, 0 templates, inherited 4 times |
| |
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-14051
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-13940
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-14706
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-14669
|
|
|
| Coded value 0 … 1
prsb03-dataelement-13904
|
|
|
| Id |
prsb03-dataelement-13904 (2021‑02‑02 21:41:22)
|
| Cardinality |
0 … 1 |
| Description |
The coded value for the organisation. |
| Operationalization |
NHS data dictionary :-
Organisation identifier
|
| Value Domain |
|
| Property |
| min length |
max length |
| 3 |
8 |
|
| Used by
|
one transaction, 0 templates, inherited 4 times |
| |
This concept is inherited by concept
Coded value in dataset prsb03-dataelement-14052
This concept is inherited by concept
Coded value in dataset prsb03-dataelement-13941
This concept is inherited by concept
Coded value in dataset prsb03-dataelement-14707
This concept is inherited by concept
Coded value in dataset prsb03-dataelement-14670
|
|
|
| Free text 0 … 1
prsb03-dataelement-13905
|
|
|
| Id |
prsb03-dataelement-13905 (2021‑02‑02 21:45:00)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13886 (2021‑02‑01 18:42:31)
|
| Description |
Free text field to provide further detail or be used if no code is available. |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited 4 times |
| |
This concept is inherited by concept
Free text in dataset prsb03-dataelement-14053
This concept is inherited by concept
Free text in dataset prsb03-dataelement-13942
This concept is inherited by concept
Free text in dataset prsb03-dataelement-14708
This concept is inherited by concept
Free text in dataset prsb03-dataelement-14671
|
|
|
| Contact details 0 … 1
prsb03-dataelement-13906
|
|
|
| Id |
prsb03-dataelement-13906 (2021‑02‑02 21:51:13)
|
| Cardinality |
0 … 1 |
| Description |
Contact details of the professional. |
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telecom
|
| Operationalization |
NHS data dictionary :-
UK telephone number
|
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited 4 times |
| |
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-14054
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-13943
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-14709
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-14672
|
|
|
| Person completing record 0 … 1
prsb03-dataelement-13907
|
|
|
| Id |
prsb03-dataelement-13907 (2021‑02‑02 22:27:51)
|
| Cardinality |
0 … 1 |
| Description |
Details of the person completing the record. |
| Used by
|
one transaction, 0 templates, inherited 12 times |
| |
|
|
|
| Name 0 … 1
prsb03-dataelement-13908
|
|
|
| Id |
prsb03-dataelement-13908 (2021‑02‑02 22:35:30)
|
| Cardinality |
0 … 1 |
| Description |
The name of the person completing the record. |
| Rationale |
Composition.author.Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 12 times |
| |
This concept is inherited by concept
Name in dataset prsb03-dataelement-19167
This concept is inherited by concept
Name in dataset prsb03-dataelement-21911
This concept is inherited by concept
Name in dataset prsb03-dataelement-19194
This concept is inherited by concept
Name in dataset prsb03-dataelement-19208
This concept is inherited by concept
Name in dataset prsb03-dataelement-16408
This concept is inherited by concept
Name in dataset prsb03-dataelement-14079
This concept is inherited by concept
Name in dataset prsb03-dataelement-14056
This concept is inherited by concept
Name in dataset prsb03-dataelement-13945
This concept is inherited by concept
Name in dataset prsb03-dataelement-14218
This concept is inherited by concept
Name in dataset prsb03-dataelement-14688
This concept is inherited by concept
Name in dataset prsb03-dataelement-14710
This concept is inherited by concept
Name in dataset prsb03-dataelement-14673
|
|
|
| Role 0 … 1
prsb03-dataelement-13909
|
|
|
| Id |
prsb03-dataelement-13909 (2021‑02‑02 22:37:50)
|
| Cardinality |
0 … 1 |
| Description |
The organisational role of the person completing the record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSJobRoleName
|
| Value Domain |
|
| Property |
| min length |
max length |
| 5 |
5 |
|
| Used by
|
one transaction, 0 templates, inherited 12 times |
| |
This concept is inherited by concept
Role in dataset prsb03-dataelement-19168
This concept is inherited by concept
Role in dataset prsb03-dataelement-21912
This concept is inherited by concept
Role in dataset prsb03-dataelement-19195
This concept is inherited by concept
Role in dataset prsb03-dataelement-19209
This concept is inherited by concept
Role in dataset prsb03-dataelement-16409
This concept is inherited by concept
Role in dataset prsb03-dataelement-14080
This concept is inherited by concept
Role in dataset prsb03-dataelement-14057
This concept is inherited by concept
Role in dataset prsb03-dataelement-13946
This concept is inherited by concept
Role in dataset prsb03-dataelement-14219
This concept is inherited by concept
Role in dataset prsb03-dataelement-14689
This concept is inherited by concept
Role in dataset prsb03-dataelement-14711
This concept is inherited by concept
Role in dataset prsb03-dataelement-14674
|
|
|
| Grade 0 … 1
prsb03-dataelement-13910
|
|
|
| Id |
prsb03-dataelement-13910 (2021‑02‑02 22:42:50)
|
| Cardinality |
0 … 1 |
| Description |
The grade of the person completing the record. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited 12 times |
| |
This concept is inherited by concept
Grade in dataset prsb03-dataelement-19169
This concept is inherited by concept
Grade in dataset prsb03-dataelement-21913
This concept is inherited by concept
Grade in dataset prsb03-dataelement-19196
This concept is inherited by concept
Grade in dataset prsb03-dataelement-19210
This concept is inherited by concept
Grade in dataset prsb03-dataelement-16410
This concept is inherited by concept
Grade in dataset prsb03-dataelement-14081
This concept is inherited by concept
Grade in dataset prsb03-dataelement-14058
This concept is inherited by concept
Grade in dataset prsb03-dataelement-13947
This concept is inherited by concept
Grade in dataset prsb03-dataelement-14220
This concept is inherited by concept
Grade in dataset prsb03-dataelement-14690
This concept is inherited by concept
Grade in dataset prsb03-dataelement-14712
This concept is inherited by concept
Grade in dataset prsb03-dataelement-14675
|
|
|
| Specialty 0 … 1
prsb03-dataelement-13911
|
|
|
| Id |
prsb03-dataelement-13911 (2021‑02‑02 22:47:46)
|
| Cardinality |
0 … 1 |
| Description |
The main specialty of the person completing the record. |
| FHIR |
PractitionerRole.specialty |
|
| Rationale |
PractitionerRole.specialty |
| Operationalization |
NHS data dictionary :-
Activity treatment function code
|
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited 12 times |
| |
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-19170
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-21914
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-19197
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-19211
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-16411
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-14082
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-14059
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-13948
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-14221
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-14691
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-14713
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-14676
|
|
|
| Organisation 0 … 1
prsb03-dataelement-13912
|
|
|
| Id |
prsb03-dataelement-13912 (2021‑02‑02 22:55:15)
|
| Cardinality |
0 … 1 |
| Description |
The organisation the person completing the record works for. |
| Used by
|
one transaction, 0 templates, inherited 12 times |
| |
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-19171
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-21915
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-19198
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-19212
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-16412
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-14083
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-14060
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-13949
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-14222
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-14692
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-14714
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-14677
|
|
|
| Coded value 0 … 1
prsb03-dataelement-13913
|
|
|
| Id |
prsb03-dataelement-13913 (2021‑02‑02 22:58:31)
|
| Cardinality |
0 … 1 |
| Description |
The coded value for the organisation. |
| Operationalization |
NHS data dictionary :-
Organisational identifier
|
| Value Domain |
|
| Property |
| min length |
max length |
| 3 |
8 |
|
| Used by
|
one transaction, 0 templates, inherited 12 times |
| |
This concept is inherited by concept
Coded value in dataset prsb03-dataelement-19172
This concept is inherited by concept
Coded value in dataset prsb03-dataelement-21916
This concept is inherited by concept
Coded value in dataset prsb03-dataelement-19199
This concept is inherited by concept
Coded value in dataset prsb03-dataelement-19213
This concept is inherited by concept
Coded value in dataset prsb03-dataelement-16413
This concept is inherited by concept
Coded value in dataset prsb03-dataelement-14084
This concept is inherited by concept
Coded value in dataset prsb03-dataelement-14061
This concept is inherited by concept
Coded value in dataset prsb03-dataelement-13950
This concept is inherited by concept
Coded value in dataset prsb03-dataelement-14223
This concept is inherited by concept
Coded value in dataset prsb03-dataelement-14693
This concept is inherited by concept
Coded value in dataset prsb03-dataelement-14715
This concept is inherited by concept
Coded value in dataset prsb03-dataelement-14678
|
|
|
| Free text 0 … 1
prsb03-dataelement-13914
|
|
|
| Id |
prsb03-dataelement-13914 (2021‑02‑02 23:02:16)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13886 (2021‑02‑01 18:42:31)
|
| Description |
Free text field to provide further detail or be used if no code is available. |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited 12 times |
| |
This concept is inherited by concept
Free text in dataset prsb03-dataelement-19173
This concept is inherited by concept
Free text in dataset prsb03-dataelement-21917
This concept is inherited by concept
Free text in dataset prsb03-dataelement-19200
This concept is inherited by concept
Free text in dataset prsb03-dataelement-19214
This concept is inherited by concept
Free text in dataset prsb03-dataelement-16414
This concept is inherited by concept
Free text in dataset prsb03-dataelement-14085
This concept is inherited by concept
Free text in dataset prsb03-dataelement-14062
This concept is inherited by concept
Free text in dataset prsb03-dataelement-13951
This concept is inherited by concept
Free text in dataset prsb03-dataelement-14224
This concept is inherited by concept
Free text in dataset prsb03-dataelement-14694
This concept is inherited by concept
Free text in dataset prsb03-dataelement-14716
This concept is inherited by concept
Free text in dataset prsb03-dataelement-14679
|
|
|
| Professional identifier 0 … 1
prsb03-dataelement-13915
|
|
|
| Id |
prsb03-dataelement-13915 (2021‑02‑02 23:06:19)
|
| Cardinality |
0 … 1 |
| Description |
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.
|
| FHIR |
PractitionerRole.Practitioner.identifier (local) Practitioner.identifer (professional) |
|
| Rationale |
Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier
(for local role identifiers)
|
| Operationalization |
NHS data dictionary :-
Professional registration entry identifier
|
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited 12 times |
| |
|
|
|
| Date completed 0 … 1
prsb03-dataelement-13916
|
|
|
| Id |
prsb03-dataelement-13916 (2021‑02‑02 23:12:04)
|
| Cardinality |
0 … 1 |
| Description |
The date and time the record was completed. |
| Rationale |
Composition.date |
| Operationalization |
Date and time. |
| Value Domain |
|
| Property |
| Timestamp precision |
| at least day, month and year, hour and minute |
|
| Used by
|
one transaction, 0 templates, inherited 12 times |
| |
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-19175
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-21919
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-19202
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-19216
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-16416
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-14087
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-14064
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-13953
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-14226
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-14696
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-14718
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-14681
|
|
|
| Contact details 0 … 1
prsb03-dataelement-13917
|
|
|
| Id |
prsb03-dataelement-13917 (2021‑02‑02 23:16:07)
|
| Cardinality |
0 … 1 |
| Description |
Contact details of the person completing the record (e.g. telephone number, email
address etc.).
|
| FHIR |
PractitionerRole.telecom |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telecom
|
| Operationalization |
NHS data dictionary :-
UK telephone number
|
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited 12 times |
| |
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-19176
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-21920
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-19203
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-19217
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-16417
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-14088
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-14065
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-13954
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-14227
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-14697
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-14719
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-14682
|
|
|
| Three-talk model cluster 0 … 1
prsb03-dataelement-13918
|
|
|
| Id |
prsb03-dataelement-13918 (2021‑02‑03 09:38:31)
|
| Cardinality |
0 … 1 |
| Description |
A structured entry in the record for clinicians following the three talk model approach
to shared decision making.
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Team talk 0 … 1
prsb03-dataelement-13919
|
|
|
| Id |
prsb03-dataelement-13919 (2021‑02‑03 09:46:21)
|
| Cardinality |
0 … 1 |
| Description |
Details of the team talk (previously choice talk) with the person (Three talk model). |
| Comment |
Overview: The team talk (previously choice talk) includes working together, describing
choices, offering support and asking about the person's goals.
Suggested phrase: "Let's work as a team to make a decision that suits you best." (Elwyn,
2020)
A key purpose of the team talk is to make the the person, who by this point recognises
that a health issue that requires a decision has been identified, aware that options
exist. The team talk can be done face-to-face, by email or letter, telephone or other
means and may include the use of patient decision support tools (Elwyn, 2016).
The NICE Shared decision making guideline (in development) states in section 1.2.7:
"Ensure the person understands they can take part as fully as they want in making
choices about their treatment or care (the ‘choice talk' stage of the three-talk model)."
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Goals and hopes 0 … 1
prsb03-dataelement-13920
|
|
|
| Id |
prsb03-dataelement-13920 (2021‑02‑03 09:51:28)
|
| Cardinality |
0 … 1 |
| Description |
The overall goals, hopes, aims or targets that the person has. Including anything
that the person wants to achieve that relates to their future health and wellbeing.
Each goal may include a description of why it is important to the person. Goals may
also be ranked in order of importance or priority to the person.
|
| Operationalization |
Free text. |
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Information and advice given 0 … 1
prsb03-dataelement-13921
|
|
|
| Id |
prsb03-dataelement-13921 (2021‑02‑03 09:53:58)
|
| Cardinality |
0 … 1 |
| Description |
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.
|
| Comment |
According to Elwyn (2016) the team talk discussion may include the following aspects:
Establishing collaboration, declaring alternatives, justifying deliberation, checking
reaction, deferring closure. See references for further information.
|
| Operationalization |
Free text. |
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Option talk 0 … 1
prsb03-dataelement-13922
|
|
|
| Id |
prsb03-dataelement-13922 (2021‑02‑03 09:57:39)
|
| Cardinality |
0 … 1 |
| Description |
Details of the option talk with the person (Three talk model). |
| Comment |
Overview: The option talk includes a discussion of the options and alternatives and
the harms and benefits of these using evidence based risk communication principles.
Suggested phrase: "Let's compare the possible options." (Elwyn, 2020)
According to Elwyn (2016) the option talk discussion may include the following key
aspects: Checking knowledge, listing options, describing options, exploring harms
and benefits, providing patient decision support, summarising.
The General Medical Council guidance on Decision making
(GMC, 2020) and consent states in section 10 that : "You must give patients the information they
want or need to make a decision. This will usually include: diagnosis and prognosis,
uncertainties about the diagnosis or prognosis, including options for further investigation,
options for treating or managing the condition, including the option to take no action,
the nature of each option, what would be involved, and the desired outcome, the potential
benefits, risks of harm, uncertainties about and likelihood of success for each option,
including the option to take no action."
The NICE Shared decision making guideline
(in development) states in section 1.2.9: "When offering tests, treatments or other healthcare services:
• openly discuss the risks, benefits and consequences of each option, making sure
the person knows this includes choosing no treatment, or no change to what they are
currently doing (the ‘option talk’ stage)."
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Options entry 0 … *
prsb03-dataelement-13923
|
|
|
| Id |
prsb03-dataelement-13923 (2021‑02‑03 10:05:52)
|
| Cardinality |
0 … * |
| Description |
Record of the options discussed. |
| Comment |
The General Medical Council (GMC) Decision Making and Consent guidance
(GMC, 2020) states that when discussing options for treating or managing a condition the clinician
involved must include the option to take no action:
"Doctors must try to find out what matters to patients so they can share relevant
information about the benefits and harms of proposed options and reasonable alternatives,
including the option to take no action (Principle 4)."
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Coded value 0 … 1
prsb03-dataelement-13924
|
|
|
| Id |
prsb03-dataelement-13924 (2021‑02‑03 10:11:10)
|
| Cardinality |
0 … 1 |
| Description |
Coded value of the option discussed. |
| Operationalization |
SNOMED CT. |
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Free text 0 … 1
prsb03-dataelement-13925
|
|
|
| Id |
prsb03-dataelement-13925 (2021‑02‑03 10:18:29)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13886 (2021‑02‑01 18:42:31)
|
| Description |
Free text field to provide further detail or be used if no code is available. |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited once |
| |
This concept is inherited by concept
Free text in dataset prsb03-dataelement-14107
|
|
|
| Benefits entry 0 … 1
prsb03-dataelement-13926
|
|
|
| Id |
prsb03-dataelement-13926 (2021‑02‑03 10:21:37)
|
| Cardinality |
0 … 1 |
| Description |
Record of the benefits discussed for each option. |
| Comment |
The General Medical Council (GMC) Decision Making and Consent guidance
(GMC, 2020) states in section 21: "You must give patients clear, accurate and up-to-date information,
based on the best available evidence, about the potential benefits and risks of harm
of each option, including the option to take no action."
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Coded value 0 … 1
prsb03-dataelement-13927
|
|
|
| Id |
prsb03-dataelement-13927 (2021‑02‑03 10:33:02)
|
| Cardinality |
0 … 1 |
| Description |
Coded value of the benefit discussed. |
| Operationalization |
SNOMED CT. |
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Free text 0 … 1
prsb03-dataelement-13928
|
|
|
| Id |
prsb03-dataelement-13928 (2021‑02‑03 10:35:02)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13886 (2021‑02‑01 18:42:31)
|
| Description |
Free text field to provide further detail or be used if no code is available. |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited once |
| |
This concept is inherited by concept
Free text in dataset prsb03-dataelement-14110
|
|
|
| Risks communication entry 0 … *
prsb03-dataelement-13929
|
|
|
| Id |
prsb03-dataelement-13929 (2021‑02‑03 10:39:01)
|
| Cardinality |
0 … * |
| Description |
Record of the risks discussed for each option. |
| Comment |
The General Medical Council (GMC) Decision Making and Consent guidance
(GMC, 2020) states in section 21 that when discussing benefits and harms a clinician should include
the following: "Recognised risks of harm that [the clinician] believe[s] anyone in
the patient’s position would want to know... the effect of the patient’s individual
clinical circumstances on the probability of a benefit or harm occurring...risks of
harm and potential benefits that the patient would consider significant for any reason...any
risk of serious harm, however unlikely it is to occur...expected harms, including
common side effects and what to do if they occur."
"It wouldn’t be reasonable to share every possible risk of harm, potential complication
or side effect. Instead, you should tailor the discussion to each individual patient,
guided by what matters to them, and share information in a way they can understand."
(Section 22).
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Coded value 0 … 1
prsb03-dataelement-13930
|
|
|
| Id |
prsb03-dataelement-13930 (2021‑02‑03 10:44:43)
|
| Cardinality |
0 … 1 |
| Description |
Coded value of the risk discussed. |
| Operationalization |
SNOMED CT. |
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Free text 0 … 1
prsb03-dataelement-13931
|
|
|
| Id |
prsb03-dataelement-13931 (2021‑02‑03 10:46:20)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13886 (2021‑02‑01 18:42:31)
|
| Description |
Free text field to provide further detail or be used if no code is available. |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited once |
| |
This concept is inherited by concept
Free text in dataset prsb03-dataelement-14112
|
|
|
| Decision talk 0 … 1
prsb03-dataelement-13932
|
|
|
| Id |
prsb03-dataelement-13932 (2021‑02‑03 11:11:58)
|
| Cardinality |
0 … 1 |
| Description |
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.
|
| Comment |
Overview: The decision talk aims to establish a person's informed preferences and
to make preference based decisions.
Suggested phrase: "Tell me what matters most to you for this decision." (Elwyn, 2020)
According to Elwyn (2016) the decision talk discussion may include the following key
aspects: Focusing on preferences, eliciting and integrating preferences, moving to
a decision, offering review.
The NICE guideline on Shared Decision Making (in draft) states:
In section 1.2.13:
"Make a joint decision or plan about treatment or care and agree when this will be
reviewed (the ‘decision’ or ‘planning’ stage)."
In section 1.2.14:
"At the end of an appointment, state clearly what decisions have been made to make
sure the person agrees with and understands what has been decided, what happens next,
what the timescales are, and when it will be reviewed."
In section 1.2.15:
"When writing up the consultation, record any decisions made along with details of
what the person said was important to them in making those decisions."
|
| Operationalization |
Free text. |
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Performing professional 0 … 1
prsb03-dataelement-13933
|
|
|
| Id |
prsb03-dataelement-13933 (2021‑02‑03 11:17:05)
|
| Cardinality |
0 … 1 |
| Description |
The professional who conducted the shared decision making conversation (Three talk
model).
|
| Relationship |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Name 0 … 1
prsb03-dataelement-13935
|
|
|
| Id |
prsb03-dataelement-13935 (2021‑02‑03 11:20:19)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13897 (2021‑02‑01 20:13:26)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited 4 times |
| |
This concept is inherited by concept
Name in dataset prsb03-dataelement-19090
This concept is inherited by concept
Name in dataset prsb03-dataelement-19185
This concept is inherited by concept
Name in dataset prsb03-dataelement-14117
This concept is inherited by concept
Name in dataset prsb03-dataelement-14208
|
|
|
| Role 0 … 1
prsb03-dataelement-13936
|
|
|
| Id |
prsb03-dataelement-13936 (2021‑02‑03 11:20:19)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13898 (2021‑02‑01 20:17:22)
|
| Description |
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etc.
|
| Rationale |
Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set:-
SDSjobrolename
|
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 4 times |
| |
This concept is inherited by concept
Role in dataset prsb03-dataelement-19091
This concept is inherited by concept
Role in dataset prsb03-dataelement-19186
This concept is inherited by concept
Role in dataset prsb03-dataelement-14118
This concept is inherited by concept
Role in dataset prsb03-dataelement-14209
|
|
|
| Grade 0 … 1
prsb03-dataelement-13937
|
|
|
| Id |
prsb03-dataelement-13937 (2021‑02‑03 11:20:19)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13899 (2021‑02‑01 20:23:02)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited 4 times |
| |
This concept is inherited by concept
Grade in dataset prsb03-dataelement-19092
This concept is inherited by concept
Grade in dataset prsb03-dataelement-19187
This concept is inherited by concept
Grade in dataset prsb03-dataelement-14119
This concept is inherited by concept
Grade in dataset prsb03-dataelement-14210
|
|
|
| Specialty 0 … 1
prsb03-dataelement-13938
|
|
|
| Id |
prsb03-dataelement-13938 (2021‑02‑03 11:20:19)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13900 (2021‑02‑01 20:28:38)
|
| Description |
The specialty of the professional e.g. physiotherapy, oncology, mental health etc. |
| Rationale |
PractitionerRole.speciality |
| Operationalization |
NHS data dictionary :-
Care professional main speciality code
|
| Value Domain |
|
| Property |
| min length |
max length |
| 3 |
3 |
|
| Used by
|
one transaction, 0 templates, inherited 4 times |
| |
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-19093
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-19188
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-14120
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-14211
|
|
|
| Professional identifier 0 … 1
prsb03-dataelement-13939
|
|
|
| Id |
prsb03-dataelement-13939 (2021‑02‑03 11:20:19)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13901 (2021‑02‑02 18:12:20)
|
| Description |
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.
|
| Rationale |
Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier
(for local role identifiers)
|
| Operationalization |
NHS data dictionary :-
Professional registration entry identifier
|
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited 4 times |
| |
|
|
|
| Organisation 0 … 1
prsb03-dataelement-13940
|
|
|
| Id |
prsb03-dataelement-13940 (2021‑02‑03 11:20:19)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13903 (2021‑02‑02 21:35:36)
|
| Description |
The name of the organisation the professional works for. |
| Used by
|
one transaction, 0 templates, inherited 4 times |
| |
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-19095
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-19190
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-14122
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-14213
|
|
|
| Coded value 0 … 1
prsb03-dataelement-13941
|
|
|
| Id |
prsb03-dataelement-13941 (2021‑02‑03 11:20:19)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13904 (2021‑02‑02 21:41:22)
|
| Description |
The coded value for the organisation. |
| Operationalization |
NHS data dictionary :-
Organisation identifier
|
| Value Domain |
|
| Property |
| min length |
max length |
| 3 |
8 |
|
| Used by
|
one transaction, 0 templates, inherited 4 times |
| |
This concept is inherited by concept
Coded value in dataset prsb03-dataelement-19096
This concept is inherited by concept
Coded value in dataset prsb03-dataelement-19191
This concept is inherited by concept
Coded value in dataset prsb03-dataelement-14123
This concept is inherited by concept
Coded value in dataset prsb03-dataelement-14214
|
|
|
| Free text 0 … 1
prsb03-dataelement-13942
|
|
|
| Id |
prsb03-dataelement-13942 (2021‑02‑03 11:20:19)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13905 (2021‑02‑02 21:45:00)
|
| Description |
Free text field to provide further detail or be used if no code is available. |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited 4 times |
| |
This concept is inherited by concept
Free text in dataset prsb03-dataelement-19097
This concept is inherited by concept
Free text in dataset prsb03-dataelement-19192
This concept is inherited by concept
Free text in dataset prsb03-dataelement-14124
This concept is inherited by concept
Free text in dataset prsb03-dataelement-14215
|
|
|
| Contact details 0 … 1
prsb03-dataelement-13943
|
|
|
| Id |
prsb03-dataelement-13943 (2021‑02‑03 11:20:19)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13906 (2021‑02‑02 21:51:13)
|
| Description |
Contact details of the professional. |
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telecom
|
| Operationalization |
NHS data dictionary :-
UK telephone number
|
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited 4 times |
| |
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-19098
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-19193
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-14125
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-14216
|
|
|
| Person completing record 0 … 1
prsb03-dataelement-13944
|
|
|
| Id |
prsb03-dataelement-13944 (2021‑02‑03 11:48:41)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13907 (2021‑02‑02 22:27:51)
|
| Description |
Details of the person completing the record. |
| Used by
|
one transaction, 0 templates, inherited once |
| |
|
|
|
| Name 0 … 1
prsb03-dataelement-13945
|
|
|
| Id |
prsb03-dataelement-13945 (2021‑02‑03 11:49:43)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13908 (2021‑02‑02 22:35:30)
|
| Description |
The name of the person completing the record. |
| Rationale |
Composition.author.Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited once |
| |
This concept is inherited by concept
Name in dataset prsb03-dataelement-14127
|
|
|
| Role 0 … 1
prsb03-dataelement-13946
|
|
|
| Id |
prsb03-dataelement-13946 (2021‑02‑03 11:49:43)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13909 (2021‑02‑02 22:37:50)
|
| Description |
The organisational role of the person completing the record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSJobRoleName
|
| Value Domain |
|
| Property |
| min length |
max length |
| 5 |
5 |
|
| Used by
|
one transaction, 0 templates, inherited once |
| |
This concept is inherited by concept
Role in dataset prsb03-dataelement-14128
|
|
|
| Grade 0 … 1
prsb03-dataelement-13947
|
|
|
| Id |
prsb03-dataelement-13947 (2021‑02‑03 11:49:43)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13910 (2021‑02‑02 22:42:50)
|
| Description |
The grade of the person completing the record. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited once |
| |
This concept is inherited by concept
Grade in dataset prsb03-dataelement-14129
|
|
|
| Specialty 0 … 1
prsb03-dataelement-13948
|
|
|
| Id |
prsb03-dataelement-13948 (2021‑02‑03 11:49:43)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13911 (2021‑02‑02 22:47:46)
|
| Description |
The main specialty of the person completing the record. |
| FHIR |
PractitionerRole.specialty |
|
| Rationale |
PractitionerRole.specialty |
| Operationalization |
NHS data dictionary :-
Activity treatment function code
|
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited once |
| |
This concept is inherited by concept
Specialty in dataset prsb03-dataelement-14130
|
|
|
| Organisation 0 … 1
prsb03-dataelement-13949
|
|
|
| Id |
prsb03-dataelement-13949 (2021‑02‑03 11:49:43)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13912 (2021‑02‑02 22:55:15)
|
| Description |
The organisation the person completing the record works for. |
| Used by
|
one transaction, 0 templates, inherited once |
| |
This concept is inherited by concept
Organisation in dataset prsb03-dataelement-14131
|
|
|
| Coded value 0 … 1
prsb03-dataelement-13950
|
|
|
| Id |
prsb03-dataelement-13950 (2021‑02‑03 11:49:43)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13913 (2021‑02‑02 22:58:31)
|
| Description |
The coded value for the organisation. |
| Operationalization |
NHS data dictionary :-
Organisational identifier
|
| Value Domain |
|
| Property |
| min length |
max length |
| 3 |
8 |
|
| Used by
|
one transaction, 0 templates, inherited once |
| |
This concept is inherited by concept
Coded value in dataset prsb03-dataelement-14132
|
|
|
| Free text 0 … 1
prsb03-dataelement-13951
|
|
|
| Id |
prsb03-dataelement-13951 (2021‑02‑03 11:49:43)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13914 (2021‑02‑02 23:02:16)
|
| Description |
Free text field to provide further detail or be used if no code is available. |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited once |
| |
This concept is inherited by concept
Free text in dataset prsb03-dataelement-14133
|
|
|
| Professional identifier 0 … 1
prsb03-dataelement-13952
|
|
|
| Id |
prsb03-dataelement-13952 (2021‑02‑03 11:49:43)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13915 (2021‑02‑02 23:06:19)
|
| Description |
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.
|
| FHIR |
PractitionerRole.Practitioner.identifier (local) Practitioner.identifer (professional) |
|
| Rationale |
Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier
(for local role identifiers)
|
| Operationalization |
NHS data dictionary :-
Professional registration entry identifier
|
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited once |
| |
|
|
|
| Date completed 0 … 1
prsb03-dataelement-13953
|
|
|
| Id |
prsb03-dataelement-13953 (2021‑02‑03 11:49:43)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13916 (2021‑02‑02 23:12:04)
|
| Description |
The date and time the record was completed. |
| Rationale |
Composition.date |
| Operationalization |
Date and time. |
| Value Domain |
|
| Property |
| Timestamp precision |
| at least day, month and year, hour and minute |
|
| Used by
|
one transaction, 0 templates, inherited once |
| |
This concept is inherited by concept
Date completed in dataset prsb03-dataelement-14135
|
|
|
| Contact details 0 … 1
prsb03-dataelement-13954
|
|
|
| Id |
prsb03-dataelement-13954 (2021‑02‑03 11:49:43)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13917 (2021‑02‑02 23:16:07)
|
| Description |
Contact details of the person completing the record (e.g. telephone number, email
address etc.).
|
| FHIR |
PractitionerRole.telecom |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telecom
|
| Operationalization |
NHS data dictionary :-
UK telephone number
|
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited once |
| |
This concept is inherited by concept
Contact details in dataset prsb03-dataelement-14136
|
|
|
| Post-appointment actions 0 … 1
prsb03-dataelement-14076
|
|
|
| Id |
prsb03-dataelement-14076 (2021‑02‑17 23:58:44)
|
| Cardinality |
0 … 1 |
| Description |
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.
|
| Comment |
1. the decision
2. the agreed course of action
3. the ongoing roles and responsibilities of each party
4. the risk-sharing agreement.."
The NICE Shared Decision Making guideline (in draft) states in section 1.2.16 that
after appointments:
"Give people resources to help them understand what was discussed and decided in their
appointment. This could be a printout summarising the options and decisions or plans
made, and links to high-quality online resources (for example, relevant NICE guidelines).
Ideally, give people this material to take away, or provide it very soon after the
appointment."
In 1.2.17:
"In secondary or tertiary care, consider asking the person if they would like a letter
detailing the information from their appointment to be sent to them and copied to
their GP. Letters should be written in line with Academy of Medical Royal Colleges
guidance on writing outpatient clinical letters to patients."
|
| Operationalization |
Free text. |
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Actions for professionals 0 … 1
prsb03-dataelement-14188
|
|
|
| Id |
prsb03-dataelement-14188 (2021‑02‑24 14:46:07)
|
| Cardinality |
0 … 1 |
| Description |
Agreed actions for the professional including planned investigations, procedures and
treatment for a person's identified conditions and priorities.
|
| Comment |
A record of the agreed actions for the professional(s) . May be structured (table),
with actions, names, dates, status, location, strategies, or free text.
1. the decision
2. the agreed course of action
3. the ongoing roles and responsibilities of each party
4. the risk-sharing agreement.."
|
| Operationalization |
Free text. |
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Actions for person or their carer 0 … 1
prsb03-dataelement-14189
|
|
|
| Id |
prsb03-dataelement-14189 (2021‑02‑24 14:52:20)
|
| Cardinality |
0 … 1 |
| Description |
Agreed actions for the person or their carer. For each action the following should
be identified: outcome expectations, including person’s expectations.
|
| Comment |
A record of the planned and requested actions for the person or their carer. May be
structured (table), with actions, names, dates, status, location, strategies, or free
text.
1. the decision
2. the agreed course of action
3. the ongoing roles and responsibilities of each party
4. the risk-sharing agreement.."
|
| Operationalization |
Free text. |
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Documenting consent 0 … 1
prsb03-dataelement-14194
|
|
|
| Id |
prsb03-dataelement-14194 (2021‑02‑25 23:10:18)
|
| Cardinality |
0 … 1 |
| Description |
A record of documents recording consent for an intervention. |
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Consent for procedure record entry 0 … *
prsb03-dataelement-14195
|
|
|
| Id |
prsb03-dataelement-14195 (2021‑02‑25 23:14:06)
|
| Cardinality |
0 … * |
| Description |
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
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| date 0 … 1
prsb03-dataelement-14196
|
|
|
| Id |
prsb03-dataelement-14196 (2021‑02‑25 23:18:47)
|
| Cardinality |
0 … 1 |
| Description |
The date when consent was taken. |
| Operationalization |
Date and time. |
| Value Domain |
|
| Property |
| Timestamp precision |
| at least day, month and year |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Location 0 … 1
prsb03-dataelement-14197
|
|
|
| Id |
prsb03-dataelement-14197 (2021‑02‑25 23:22:58)
|
| Cardinality |
0 … 1 |
| Description |
The location where consent was taken. |
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Coded value 0 … 1
prsb03-dataelement-14198
|
|
|
|
|
| Free text 0 … 1
prsb03-dataelement-14199
|
|
|
| Id |
prsb03-dataelement-14199 (2021‑02‑25 23:26:22)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13886 (2021‑02‑01 18:42:31)
|
| Description |
Free text field to provide further detail or be used if no code is available. |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited once |
| |
This concept is inherited by concept
Free text in dataset prsb03-dataelement-14699
|
|
|
| Consent form type 0 … 1
prsb03-dataelement-14200
|
|
|
| Id |
prsb03-dataelement-14200 (2021‑02‑25 23:33:46)
|
| Cardinality |
0 … 1 |
| Description |
Record of consent form used.
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Coded value 0 … 1
prsb03-dataelement-14201
|
|
|
| Id |
prsb03-dataelement-14201 (2021‑02‑25 23:37:05)
|
| Cardinality |
0 … 1 |
| Description |
The coded value for the consent form used. |
| Operationalization |
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)|
|
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Free text 0 … 1
prsb03-dataelement-14202
|
|
|
| Id |
prsb03-dataelement-14202 (2021‑02‑25 23:41:17)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13886 (2021‑02‑01 18:42:31)
|
| Description |
Free text field to provide further detail or be used if no code is available. |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Consent form location 0 … 1
prsb03-dataelement-14203
|
|
|
| Id |
prsb03-dataelement-14203 (2021‑02‑25 23:44:55)
|
| Cardinality |
0 … 1 |
| Description |
The URL for the consent form. |
| Operationalization |
Free text. |
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Consent form MIME type 0 … 1
prsb03-dataelement-14204
|
|
|
| Id |
prsb03-dataelement-14204 (2021‑02‑25 23:50:13)
|
| Cardinality |
0 … 1 |
| Description |
MIME type of the document e.g. application, pdf, website. |
| Operationalization |
Free text. |
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Performing professional 0 … 1
prsb03-dataelement-14206
|
|
|
| Id |
prsb03-dataelement-14206 (2021‑02‑25 23:56:44)
|
| Cardinality |
0 … 1 |
| Description |
The professional who completed the consent form. |
| Relationship |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Organisation 0 … 1
prsb03-dataelement-14207
|
|
|
| Id |
prsb03-dataelement-14207 (2021‑02‑25 23:57:55)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13934 (2021‑02‑03 11:20:19)
|
| Description |
The name of the organisation the professional works for. |
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Name 0 … 1
prsb03-dataelement-14208
|
|
|
| Id |
prsb03-dataelement-14208 (2021‑02‑25 23:57:55)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13935 (2021‑02‑03 11:20:19)
|
| Description |
The name of the professional. |
| Rationale |
Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Role 0 … 1
prsb03-dataelement-14209
|
|
|
| Id |
prsb03-dataelement-14209 (2021‑02‑25 23:57:55)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13936 (2021‑02‑03 11:20:19)
|
| Description |
The role the professional has in relation to the person e.g. GP, physiotherapist,
community nurse, social worker etc.
|
| Rationale |
Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set:-
SDSjobrolename
|
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Grade 0 … 1
prsb03-dataelement-14210
|
|
|
| Id |
prsb03-dataelement-14210 (2021‑02‑25 23:57:55)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13937 (2021‑02‑03 11:20:19)
|
| Description |
The grade of the professional. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Specialty 0 … 1
prsb03-dataelement-14211
|
|
|
| Id |
prsb03-dataelement-14211 (2021‑02‑25 23:57:55)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13938 (2021‑02‑03 11:20:19)
|
| Description |
The specialty of the professional e.g. physiotherapy, oncology, mental health etc. |
| Rationale |
PractitionerRole.speciality |
| Operationalization |
NHS data dictionary :-
Care professional main speciality code
|
| Value Domain |
|
| Property |
| min length |
max length |
| 3 |
3 |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Professional identifier 0 … 1
prsb03-dataelement-14212
|
|
|
| Id |
prsb03-dataelement-14212 (2021‑02‑25 23:57:55)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13939 (2021‑02‑03 11:20:19)
|
| Description |
Professional identifier for the professional e.g. GMC number, HCPC number etc or the
personal identifier used by the local organisation.
|
| Rationale |
Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier
(for local role identifiers)
|
| Operationalization |
NHS data dictionary :-
Professional registration entry identifier
|
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Organisation 0 … 1
prsb03-dataelement-14213
|
|
|
| Id |
prsb03-dataelement-14213 (2021‑02‑25 23:57:55)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13940 (2021‑02‑03 11:20:19)
|
| Description |
The name of the organisation the professional works for. |
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Coded value 0 … 1
prsb03-dataelement-14214
|
|
|
| Id |
prsb03-dataelement-14214 (2021‑02‑25 23:57:55)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13941 (2021‑02‑03 11:20:19)
|
| Description |
The coded value for the organisation. |
| Operationalization |
NHS data dictionary :-
Organisation identifier
|
| Value Domain |
|
| Property |
| min length |
max length |
| 3 |
8 |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Free text 0 … 1
prsb03-dataelement-14215
|
|
|
| Id |
prsb03-dataelement-14215 (2021‑02‑25 23:57:55)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13942 (2021‑02‑03 11:20:19)
|
| Description |
Free text field to provide further detail or be used if no code is available. |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Contact details 0 … 1
prsb03-dataelement-14216
|
|
|
| Id |
prsb03-dataelement-14216 (2021‑02‑25 23:57:55)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13943 (2021‑02‑03 11:20:19)
|
| Description |
Contact details of the professional. |
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telecom
|
| Operationalization |
NHS data dictionary :-
UK telephone number
|
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Person completing record 0 … 1
prsb03-dataelement-14217
|
|
|
| Id |
prsb03-dataelement-14217 (2021‑02‑26 00:07:31)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13907 (2021‑02‑02 22:27:51)
|
| Description |
Details of the person completing the record. |
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Name 0 … 1
prsb03-dataelement-14218
|
|
|
| Id |
prsb03-dataelement-14218 (2021‑02‑26 00:08:20)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13908 (2021‑02‑02 22:35:30)
|
| Description |
The name of the person completing the record. |
| Rationale |
Composition.author.Practitioner.name |
| Operationalization |
Free text. |
| Value Domain |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Role 0 … 1
prsb03-dataelement-14219
|
|
|
| Id |
prsb03-dataelement-14219 (2021‑02‑26 00:08:20)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13909 (2021‑02‑02 22:37:50)
|
| Description |
The organisational role of the person completing the record. |
| FHIR |
PractitionerRole.code of the practitioner completing the record |
|
| Rationale |
Composition.author.Practitioner.PractitionerRole.code |
| Operationalization |
FHIR value set :-
SDSJobRoleName
|
| Value Domain |
|
| Property |
| min length |
max length |
| 5 |
5 |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Grade 0 … 1
prsb03-dataelement-14220
|
|
|
| Id |
prsb03-dataelement-14220 (2021‑02‑26 00:08:20)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13910 (2021‑02‑02 22:42:50)
|
| Description |
The grade of the person completing the record. |
| Rationale |
PractitionerRole.code |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Specialty 0 … 1
prsb03-dataelement-14221
|
|
|
| Id |
prsb03-dataelement-14221 (2021‑02‑26 00:08:20)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13911 (2021‑02‑02 22:47:46)
|
| Description |
The main specialty of the person completing the record. |
| FHIR |
PractitionerRole.specialty |
|
| Rationale |
PractitionerRole.specialty |
| Operationalization |
NHS data dictionary :-
Activity treatment function code
|
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Organisation 0 … 1
prsb03-dataelement-14222
|
|
|
| Id |
prsb03-dataelement-14222 (2021‑02‑26 00:08:20)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13912 (2021‑02‑02 22:55:15)
|
| Description |
The organisation the person completing the record works for. |
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Coded value 0 … 1
prsb03-dataelement-14223
|
|
|
|
|
| Free text 0 … 1
prsb03-dataelement-14224
|
|
|
| Id |
prsb03-dataelement-14224 (2021‑02‑26 00:08:20)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13914 (2021‑02‑02 23:02:16)
|
| Description |
Free text field to provide further detail or be used if no code is available. |
| Operationalization |
Free text. |
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Professional identifier 0 … 1
prsb03-dataelement-14225
|
|
|
| Id |
prsb03-dataelement-14225 (2021‑02‑26 00:08:20)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13915 (2021‑02‑02 23:06:19)
|
| Description |
Professional identifier for the person completing the record e.g. GMC number, HCPC
number etc, or the personal identifier used by the local organisation.
|
| FHIR |
PractitionerRole.Practitioner.identifier (local) Practitioner.identifer (professional) |
|
| Rationale |
Practitioner.identifier (for professional national identifiers),PractitionerRole.identifier
(for local role identifiers)
|
| Operationalization |
NHS data dictionary :-
Professional registration entry identifier
|
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Date completed 0 … 1
prsb03-dataelement-14226
|
|
|
| Id |
prsb03-dataelement-14226 (2021‑02‑26 00:08:20)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13916 (2021‑02‑02 23:12:04)
|
| Description |
The date and time the record was completed. |
| Rationale |
Composition.date |
| Operationalization |
Date and time. |
| Value Domain |
|
| Property |
| Timestamp precision |
| at least day, month and year, hour and minute |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|
| Contact details 0 … 1
prsb03-dataelement-14227
|
|
|
| Id |
prsb03-dataelement-14227 (2021‑02‑26 00:08:20)
|
| Cardinality |
0 … 1 |
| Concept inherits from |
prsb03-dataelement-13917 (2021‑02‑02 23:16:07)
|
| Description |
Contact details of the person completing the record (e.g. telephone number, email
address etc.).
|
| FHIR |
PractitionerRole.telecom |
|
| Rationale |
Practitioner.telecom
PractitionerRole.telecom
Organisation.telecom
|
| Operationalization |
NHS data dictionary :-
UK telephone number
|
| Value Domain |
|
| Property |
|
| Used by
|
one transaction, 0 templates, inherited 0 times |
| |
|
|
|