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draft Transaction Shared Decision Making 2.16.840.1.113883.3.1937.777.28.4.229

Data Set  2.16.840.1.113883.3.1937.777.28.1.1

Name Id
draft Shared Decision Making (0.3) 2.16.840.1.113883.3.1937.777.28.4.229
Version / effective date Expiration date
2021‑01‑27 16:41:31
Description
Version incremented from 0.2 to 0.3 before start of new phase
Name Details [‑]
folder draft Contacts with professionals 0 … 1
prsb03-dataelement-169
Id prsb03-dataelement-169 (2018‑10‑31)
Cardinality 0 … 1
Description The details of the person’s contact with a professional.
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft Contacts with professionals record entry 0 … *
prsb03-dataelement-10718
Id prsb03-dataelement-10718 (2019‑02‑08 13:49:22)
Cardinality 0 … *
Description This is a contacts record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
target Used by one transaction, 0 templates, inherited 0 times
 
draft Date and time of contact 0 … 1
prsb03-dataelement-10069
Id prsb03-dataelement-10069 (2018‑10‑31)
Cardinality 0 … 1
Description Date and time of the contact.

Properties

FHIR Encounter.period
Rationale Encounter.period
Operationalization Date and time.
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft Location of contact 0 … 1
prsb03-dataelement-10075
Id prsb03-dataelement-10075 (2018‑10‑31)
Cardinality 0 … 1
Description The location where the contact took place.
target Used by one transaction, 0 templates, inherited 0 times
 
draft Coded value 0 … 1
prsb03-dataelement-13513
Id prsb03-dataelement-13513 (2020‑09‑03 18:01:56)
Cardinality 0 … 1
Description The coded value for location
Rationale Encounter.location.name
Operationalization NHS data dictionary : - Organisation service code
Value Domain
Property
min length max length
3 5
target Used by one transaction, 0 templates, inherited 0 times
 
draft Free text 0 … 1
prsb03-dataelement-13514
Id prsb03-dataelement-13514 (2020‑09‑03 18:04:13)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
Description Free text field to be used if no code is available
Operationalization Free text
Value Domain
Property
max length
150
target Used by one transaction, 0 templates, inherited once
 
folder draft Seen by 0 … 1
prsb03-dataelement-10077
Id prsb03-dataelement-10077 (2018‑10‑31)
Cardinality 0 … 1
Description The professional that saw the person.

Properties

FHIR Encounter.participant
target Used by one transaction, 0 templates, inherited 0 times
 
draft Name 0 … 1
prsb03-dataelement-13515
Id prsb03-dataelement-13515 (2020‑09‑03 18:13:01)
Cardinality 0 … 1
Description The name of the professional that saw the person
Rationale Encounter.participant
Operationalization Free text
Value Domain
Property
max length
70
target Used by one transaction, 0 templates, inherited 0 times
 
draft Role 0 … 1
prsb03-dataelement-13758
Id prsb03-dataelement-13758 (2020‑09‑29 12:37:26)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-10710 (2018‑12‑04 15:32:09)
Description The role of the person providing the service.
Operationalization FHIR values set : - sdsjobrole
Value Domain
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft Responsible professional 0 … 1
prsb03-dataelement-10072
Id prsb03-dataelement-10072 (2018‑10‑31)
Cardinality 0 … 1
Description The name and role of the professional that had overall responsibility for the person e.g. consultant, nurse consultant, midwife, allied health professional (may not have actually seen the person).

Properties

FHIR Encounter.participant
target Used by one transaction, 0 templates, inherited 0 times
 
draft Name 0 … 1
prsb03-dataelement-10988
Id prsb03-dataelement-10988 (2019‑05‑23 18:36:10)
Cardinality 0 … 1
Description The name of the responsible professional.
Rationale Encounter.participant
Operationalization Free text
Value Domain
Property
max length
70
target Used by one transaction, 0 templates, inherited 0 times
 
draft Role 0 … 1
prsb03-dataelement-10989
Id prsb03-dataelement-10989 (2019‑05‑23 18:36:53)
Cardinality 0 … 1
Description The role of the responsible professional
Rationale Encounter.participant.type
Operationalization FHIR value set : - sdsjobrole
Value Domain
target Used by one transaction, 0 templates, inherited 0 times
 
draft 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
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft 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
Context Implementation guidance.
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."
target Used by one transaction, 0 templates, inherited 0 times
 
draft 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
target Used by one transaction, 0 templates, inherited 0 times
 
draft 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
target Used by one transaction, 0 templates, inherited 0 times
 
draft 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
target Used by one transaction, 0 templates, inherited 0 times
 
draft Consultation method 0 … 1
prsb03-dataelement-10071
Id prsb03-dataelement-10071 (2018‑10‑31)
Cardinality 0 … 1
Description Consultation method used e.g. face to face, telephone

Properties

FHIR Handled as text in the transfer of care
Rationale Extension
Operationalization NHS data dictionary - Consultation medium
Value Domain
Property
max length
2
target Used by one transaction, 0 templates, inherited 0 times
 
draft Specialty 0 … 1
prsb03-dataelement-10073
Id prsb03-dataelement-10073 (2018‑10‑31)
Cardinality 0 … 1
Description The specialty e.g. physiotherapy, oncology, mental health etc

Properties

FHIR Encounter.participant.individual.Practitioner.PractitionerRole.speciality (of the consultant responsible for the encounter)
Rationale Encounter.participant.individual.Practitioner.PractitionerRole.speciality
Operationalization NHS data dictionary - Activity treatment function code
Value Domain
Property
max length
3
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft Professionals present 0 … *
prsb03-dataelement-10078
Id prsb03-dataelement-10078 (2018‑10‑31)
Cardinality 0 … *
Description The name, role of the additional individuals or team members including consultant(s), nurse consultant(s), allied health professional(s), social worker(s)

Properties

FHIR Encounter.participant
target Used by one transaction, 0 templates, inherited 0 times
 
draft Name 0 … 1
prsb03-dataelement-10990
Id prsb03-dataelement-10990 (2019‑05‑23 18:51:51)
Cardinality 0 … 1
Description The name of the professional present
Rationale Encounter.participant
Operationalization Free text
Value Domain
Property
max length
70
target Used by one transaction, 0 templates, inherited 0 times
 
draft Role 0 … 1
prsb03-dataelement-10991
Id prsb03-dataelement-10991 (2019‑05‑23 18:52:37)
Cardinality 0 … 1
Description The role of the professional present.
Rationale Encounter.participant.type
Operationalization FHIR value set : - sdsjobrole
Value Domain
target Used by one transaction, 0 templates, inherited 0 times
 
draft Person accompanying patient 0 … *
prsb03-dataelement-10079
Id prsb03-dataelement-10079 (2018‑10‑31)
Cardinality 0 … *
Description Identify, where clinically relevant, others accompanying the patient, e.g. parent, relative, friend. Includes: Name, Relationship, role (e.g. informal carer).

Properties

FHIR Encounter.participant
Rationale Encounter.participant
Operationalization NHS data dictionary : - Person full name
Value Domain
Property
max length
70
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft Problem list 0 … 1
prsb03-dataelement-10927
Id prsb03-dataelement-10927 (2019‑04‑30 17:00:00)
Cardinality 0 … 1
Description A summary of the problems that require investigation or treatment.
target Used by one transaction, 0 templates, inherited once
 
folder draft Problem list record entry 0 … *
prsb03-dataelement-10928
Id prsb03-dataelement-10928 (2019‑04‑30 17:01:01)
Cardinality 0 … *
Description This is a problem list record entry.

There may be 0 to many record entries under problem list.

Each record entry is made up of a number of elements or data items.
target Used by one transaction, 0 templates, inherited once
 
draft Date 0 … 1
prsb03-dataelement-10929
Id prsb03-dataelement-10929 (2019‑04‑30 17:04:55)
Cardinality 0 … 1
Description The date the problem was identified.
Relationship
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year, hour and minute
target Used by one transaction, 0 templates, inherited once
 
folder draft Location 0 … 1
prsb03-dataelement-10931
Id prsb03-dataelement-10931 (2019‑04‑30 17:07:45)
Cardinality 0 … 1
Description The location the problem was identified.
Relationship
target Used by one transaction, 0 templates, inherited once
 
draft Coded value 0 … 1
prsb03-dataelement-13242
Id prsb03-dataelement-13242 (2020‑07‑27 18:27:08)
Cardinality 0 … 1
Description The coded value for location.
Operationalization NHS data dictionary : - Organisation data service code
Value Domain
Property
min length max length
3 5
target Used by one transaction, 0 templates, inherited 5 times
 
draft Free text 0 … 1
prsb03-dataelement-13243
Id prsb03-dataelement-13243 (2020‑07‑27 18:31:13)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
Description Free text field to be used if no code is available
Operationalization Free text
Value Domain
Property
max length
150
target Used by one transaction, 0 templates, inherited 5 times
 
folder draft Problem 1 … 1 Mandatory
prsb03-dataelement-10932
Id prsb03-dataelement-10932 (2019‑04‑30 17:08:40)
Cardinality 1 … 1 Mandatory
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, and social or behavioural issues
Relationship
target Used by one transaction, 0 templates, inherited 5 times
 
draft Coded value 0 … 1
prsb03-dataelement-13244
Id prsb03-dataelement-13244 (2020‑07‑27 18:43:32)
Cardinality 0 … 1
Description The coded value for the problem list.
Operationalization SNOMED CT : - ^1127581000000103 |Health issues simple reference set|
Value Domain
target Used by one transaction, 0 templates, inherited 5 times
 
draft Free text 0 … 1
prsb03-dataelement-13245
Id prsb03-dataelement-13245 (2020‑07‑27 18:46:30)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
Description Free text field to be used if no code is available
Operationalization Free text
Value Domain
Property
max length
150
target Used by one transaction, 0 templates, inherited 22 times
 
folder draft 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.
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft 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.
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft 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.
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft 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)."
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft 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


target Used by one transaction, 0 templates, inherited 0 times
 
folder draft 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."
target Used by one transaction, 0 templates, inherited 0 times
 
draft 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
target Used by one transaction, 0 templates, inherited 0 times
 
draft 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
target Used by one transaction, 0 templates, inherited 0 times
 
draft 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
target Used by one transaction, 0 templates, inherited 0 times
 
draft 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
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft 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
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft 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)."
target Used by one transaction, 0 templates, inherited 0 times
 
draft 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
target Used by one transaction, 0 templates, inherited 0 times
 
draft Free text 0 … 1
prsb03-dataelement-14107
Id prsb03-dataelement-14107 (2021‑02‑22 13:16:02)
Cardinality 0 … 1
Concept inherits from draft 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
max length
150
target Used by one transaction, 0 templates, inherited once
 
folder draft 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).
target Used by one transaction, 0 templates, inherited 0 times
 
draft 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
target Used by one transaction, 0 templates, inherited 0 times
 
draft Free text 0 … 1
prsb03-dataelement-14112
Id prsb03-dataelement-14112 (2021‑02‑22 13:16:02)
Cardinality 0 … 1
Concept inherits from draft 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
max length
150
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft 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."
target Used by one transaction, 0 templates, inherited 0 times
 
draft 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
target Used by one transaction, 0 templates, inherited 0 times
 
draft Free text 0 … 1
prsb03-dataelement-14110
Id prsb03-dataelement-14110 (2021‑02‑22 13:16:02)
Cardinality 0 … 1
Concept inherits from draft 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
max length
150
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft 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."
target Used by one transaction, 0 templates, inherited 0 times
 
draft 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
target Used by one transaction, 0 templates, inherited 0 times
 
draft 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
target Used by one transaction, 0 templates, inherited 0 times
 
draft 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
target Used by one transaction, 0 templates, inherited 0 times
 
draft 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
target Used by one transaction, 0 templates, inherited 0 times
 
draft 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
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft 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.
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft 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."
target Used by one transaction, 0 templates, inherited 0 times
 
draft 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
target Used by one transaction, 0 templates, inherited 0 times
 
draft Free text 0 … 1
prsb03-dataelement-14193
Id prsb03-dataelement-14193 (2021‑02‑24 15:12:01)
Cardinality 0 … 1
Concept inherits from draft 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
max length
150
target Used by one transaction, 0 templates, inherited 0 times
 
draft 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
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft 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). 
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft 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.
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft 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.
target Used by one transaction, 0 templates, inherited 0 times
 
draft 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
target Used by one transaction, 0 templates, inherited 0 times
 
draft 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
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft 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.
target Used by one transaction, 0 templates, inherited 0 times
 
draft 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
target Used by one transaction, 0 templates, inherited 0 times
 
draft Free text 0 … 1
prsb03-dataelement-14306
Id prsb03-dataelement-14306 (2021‑06‑13 21:36:42)
Cardinality 0 … 1
Concept inherits from draft 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
max length
150
target Used by one transaction, 0 templates, inherited 0 times
 
draft 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
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft 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.
target Used by one transaction, 0 templates, inherited 0 times
 
draft 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
target Used by one transaction, 0 templates, inherited 0 times
 
draft 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
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft 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. 
target Used by one transaction, 0 templates, inherited 0 times
 
draft 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
target Used by one transaction, 0 templates, inherited 0 times
 
draft 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
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft 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.  

target Used by one transaction, 0 templates, inherited 0 times
 
folder draft 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.  

target Used by one transaction, 0 templates, inherited 0 times
 
draft 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
target Used by one transaction, 0 templates, inherited 0 times
 
draft 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
target Used by one transaction, 0 templates, inherited 0 times
 
draft 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
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft 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.’

target Used by one transaction, 0 templates, inherited 0 times
 
draft 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
target Used by one transaction, 0 templates, inherited 0 times
 
draft 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
target Used by one transaction, 0 templates, inherited 0 times
 
draft 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
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft 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
target Used by one transaction, 0 templates, inherited 0 times
 
draft Organisation 0 … 1
prsb03-dataelement-14116
Id prsb03-dataelement-14116 (2021‑02‑22 13:16:02)
Cardinality 0 … 1
Concept inherits from cancelled prsb03-dataelement-13934 (2021‑02‑03 11:20:19)
Description The name of the organisation the professional works for.
Value Domain
target Used by one transaction, 0 templates, inherited once
 
draft Name 0 … 1
prsb03-dataelement-14117
Id prsb03-dataelement-14117 (2021‑02‑22 13:16:02)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13935 (2021‑02‑03 11:20:19)
Description The name of the professional.
Rationale Practitioner.name
Operationalization Free text.
Value Domain
Property
max length
70
target Used by one transaction, 0 templates, inherited once
 
draft Role 0 … 1
prsb03-dataelement-14118
Id prsb03-dataelement-14118 (2021‑02‑22 13:16:02)
Cardinality 0 … 1
Concept inherits from draft 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
target Used by one transaction, 0 templates, inherited once
 
draft Grade 0 … 1
prsb03-dataelement-14119
Id prsb03-dataelement-14119 (2021‑02‑22 13:16:02)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13937 (2021‑02‑03 11:20:19)
Description The grade of the professional.
Rationale PractitionerRole.code
Operationalization Free text.
Value Domain
Property
max length
150
target Used by one transaction, 0 templates, inherited once
 
draft Specialty 0 … 1
prsb03-dataelement-14120
Id prsb03-dataelement-14120 (2021‑02‑22 13:16:02)
Cardinality 0 … 1
Concept inherits from draft 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
target Used by one transaction, 0 templates, inherited once
 
draft Professional identifier 0 … 1
prsb03-dataelement-14121
Id prsb03-dataelement-14121 (2021‑02‑22 13:16:02)
Cardinality 0 … 1
Concept inherits from draft 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
max length
32
target Used by one transaction, 0 templates, inherited once
 
folder draft Organisation 0 … 1
prsb03-dataelement-14122
Id prsb03-dataelement-14122 (2021‑02‑22 13:16:02)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13940 (2021‑02‑03 11:20:19)
Description The name of the organisation the professional works for.
target Used by one transaction, 0 templates, inherited once
 
draft Coded value 0 … 1
prsb03-dataelement-14123
Id prsb03-dataelement-14123 (2021‑02‑22 13:16:02)
Cardinality 0 … 1
Concept inherits from draft 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
target Used by one transaction, 0 templates, inherited once
 
draft Free text 0 … 1
prsb03-dataelement-14124
Id prsb03-dataelement-14124 (2021‑02‑22 13:16:02)
Cardinality 0 … 1
Concept inherits from draft 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
max length
150
target Used by one transaction, 0 templates, inherited once
 
draft Contact details 0 … 1
prsb03-dataelement-14125
Id prsb03-dataelement-14125 (2021‑02‑22 13:16:02)
Cardinality 0 … 1
Concept inherits from draft 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
max length
35
target Used by one transaction, 0 templates, inherited once
 
folder draft Person completing record 0 … 1
prsb03-dataelement-14126
Id prsb03-dataelement-14126 (2021‑02‑22 13:16:02)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13944 (2021‑02‑03 11:48:41)
Description Details of the person completing the record.
target Used by one transaction, 0 templates, inherited 0 times
 
draft Name 0 … 1
prsb03-dataelement-14127
Id prsb03-dataelement-14127 (2021‑02‑22 13:16:02)
Cardinality 0 … 1
Concept inherits from draft 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
target Used by one transaction, 0 templates, inherited 0 times
 
draft Role 0 … 1
prsb03-dataelement-14128
Id prsb03-dataelement-14128 (2021‑02‑22 13:16:02)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13946 (2021‑02‑03 11:49:43)
Description The organisational role of the person completing the record.

Properties

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
target Used by one transaction, 0 templates, inherited 0 times
 
draft Grade 0 … 1
prsb03-dataelement-14129
Id prsb03-dataelement-14129 (2021‑02‑22 13:16:02)
Cardinality 0 … 1
Concept inherits from draft 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
max length
150
target Used by one transaction, 0 templates, inherited 0 times
 
draft Specialty 0 … 1
prsb03-dataelement-14130
Id prsb03-dataelement-14130 (2021‑02‑22 13:16:02)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13948 (2021‑02‑03 11:49:43)
Description The main specialty of the person completing the record.

Properties

FHIR PractitionerRole.specialty
Rationale PractitionerRole.specialty
Operationalization NHS data dictionary :- Activity treatment function code
Value Domain
Property
max length
3
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft Organisation 0 … 1
prsb03-dataelement-14131
Id prsb03-dataelement-14131 (2021‑02‑22 13:16:02)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13949 (2021‑02‑03 11:49:43)
Description The organisation the person completing the record works for.
target Used by one transaction, 0 templates, inherited 0 times
 
draft Coded value 0 … 1
prsb03-dataelement-14132
Id prsb03-dataelement-14132 (2021‑02‑22 13:16:02)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13950 (2021‑02‑03 11:49:43)
Description The coded value for the organisation.
Operationalization NHS data dictionary :- Organisational identifier
Value Domain
Property
min length max length
3 8
target Used by one transaction, 0 templates, inherited 0 times
 
draft Free text 0 … 1
prsb03-dataelement-14133
Id prsb03-dataelement-14133 (2021‑02‑22 13:16:02)
Cardinality 0 … 1
Concept inherits from draft 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
max length
150
target Used by one transaction, 0 templates, inherited 0 times
 
draft Professional identifier 0 … 1
prsb03-dataelement-14134
Id prsb03-dataelement-14134 (2021‑02‑22 13:16:02)
Cardinality 0 … 1
Concept inherits from draft 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.

Properties

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
max length
32
target Used by one transaction, 0 templates, inherited 0 times
 
draft Date completed 0 … 1
prsb03-dataelement-14135
Id prsb03-dataelement-14135 (2021‑02‑22 13:16:02)
Cardinality 0 … 1
Concept inherits from draft 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
target Used by one transaction, 0 templates, inherited 0 times
 
draft Contact details 0 … 1
prsb03-dataelement-14136
Id prsb03-dataelement-14136 (2021‑02‑22 13:16:02)
Cardinality 0 … 1
Concept inherits from draft 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.).

Properties

FHIR PractitionerRole.telecom
Rationale Practitioner.telecom



PractitionerRole.telecom



Organisation.telecom
Operationalization NHS data dictionary :- UK telephone number
Value Domain
Property
max length
35
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft 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
Kings Fund (2011):



"There should be a formal system for documenting:



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.
target Used by one transaction, 0 templates, inherited 0 times
 
draft 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.



Kings Fund (2011):



"There should be a formal system for documenting:



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
target Used by one transaction, 0 templates, inherited 0 times
 
draft 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.



Kings Fund (2011):



"There should be a formal system for documenting:



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
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft 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.
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft 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
target Used by one transaction, 0 templates, inherited 0 times
 
draft 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
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft 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.
target Used by one transaction, 0 templates, inherited 0 times
 
draft Coded value 0 … 1
prsb03-dataelement-14198
Id prsb03-dataelement-14198 (2021‑02‑25 23:24:04)
Cardinality 0 … 1
Description The coded value for location.
Operationalization NHS data dictionary : -  Organisation data service code
Value Domain
target Used by one transaction, 0 templates, inherited 0 times
 
draft Free text 0 … 1
prsb03-dataelement-14199
Id prsb03-dataelement-14199 (2021‑02‑25 23:26:22)
Cardinality 0 … 1
Concept inherits from draft 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
max length
150
target Used by one transaction, 0 templates, inherited once
 
folder draft 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.
target Used by one transaction, 0 templates, inherited 0 times
 
draft 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
target Used by one transaction, 0 templates, inherited 0 times
 
draft Free text 0 … 1
prsb03-dataelement-14202
Id prsb03-dataelement-14202 (2021‑02‑25 23:41:17)
Cardinality 0 … 1
Concept inherits from draft 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
max length
150
target Used by one transaction, 0 templates, inherited 0 times
 
draft 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
target Used by one transaction, 0 templates, inherited 0 times
 
draft 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
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft 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
target Used by one transaction, 0 templates, inherited 0 times
 
draft Organisation 0 … 1
prsb03-dataelement-14207
Id prsb03-dataelement-14207 (2021‑02‑25 23:57:55)
Cardinality 0 … 1
Concept inherits from cancelled prsb03-dataelement-13934 (2021‑02‑03 11:20:19)
Description The name of the organisation the professional works for.
Value Domain
target Used by one transaction, 0 templates, inherited 0 times
 
draft Name 0 … 1
prsb03-dataelement-14208
Id prsb03-dataelement-14208 (2021‑02‑25 23:57:55)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13935 (2021‑02‑03 11:20:19)
Description The name of the professional.
Rationale Practitioner.name
Operationalization Free text.
Value Domain
Property
max length
70
target Used by one transaction, 0 templates, inherited 0 times
 
draft Role 0 … 1
prsb03-dataelement-14209
Id prsb03-dataelement-14209 (2021‑02‑25 23:57:55)
Cardinality 0 … 1
Concept inherits from draft 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
target Used by one transaction, 0 templates, inherited 0 times
 
draft Grade 0 … 1
prsb03-dataelement-14210
Id prsb03-dataelement-14210 (2021‑02‑25 23:57:55)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13937 (2021‑02‑03 11:20:19)
Description The grade of the professional.
Rationale PractitionerRole.code
Operationalization Free text.
Value Domain
Property
max length
150
target Used by one transaction, 0 templates, inherited 0 times
 
draft Specialty 0 … 1
prsb03-dataelement-14211
Id prsb03-dataelement-14211 (2021‑02‑25 23:57:55)
Cardinality 0 … 1
Concept inherits from draft 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
target Used by one transaction, 0 templates, inherited 0 times
 
draft Professional identifier 0 … 1
prsb03-dataelement-14212
Id prsb03-dataelement-14212 (2021‑02‑25 23:57:55)
Cardinality 0 … 1
Concept inherits from draft 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
max length
32
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft Organisation 0 … 1
prsb03-dataelement-14213
Id prsb03-dataelement-14213 (2021‑02‑25 23:57:55)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13940 (2021‑02‑03 11:20:19)
Description The name of the organisation the professional works for.
target Used by one transaction, 0 templates, inherited 0 times
 
draft Coded value 0 … 1
prsb03-dataelement-14214
Id prsb03-dataelement-14214 (2021‑02‑25 23:57:55)
Cardinality 0 … 1
Concept inherits from draft 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
target Used by one transaction, 0 templates, inherited 0 times
 
draft Free text 0 … 1
prsb03-dataelement-14215
Id prsb03-dataelement-14215 (2021‑02‑25 23:57:55)
Cardinality 0 … 1
Concept inherits from draft 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
max length
150
target Used by one transaction, 0 templates, inherited 0 times
 
draft Contact details 0 … 1
prsb03-dataelement-14216
Id prsb03-dataelement-14216 (2021‑02‑25 23:57:55)
Cardinality 0 … 1
Concept inherits from draft 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
max length
35
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft Person completing record 0 … 1
prsb03-dataelement-14217
Id prsb03-dataelement-14217 (2021‑02‑26 00:07:31)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13907 (2021‑02‑02 22:27:51)
Description Details of the person completing the record.
target Used by one transaction, 0 templates, inherited 0 times
 
draft Name 0 … 1
prsb03-dataelement-14218
Id prsb03-dataelement-14218 (2021‑02‑26 00:08:20)
Cardinality 0 … 1
Concept inherits from draft 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
target Used by one transaction, 0 templates, inherited 0 times
 
draft Role 0 … 1
prsb03-dataelement-14219
Id prsb03-dataelement-14219 (2021‑02‑26 00:08:20)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13909 (2021‑02‑02 22:37:50)
Description The organisational role of the person completing the record.

Properties

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
target Used by one transaction, 0 templates, inherited 0 times
 
draft Grade 0 … 1
prsb03-dataelement-14220
Id prsb03-dataelement-14220 (2021‑02‑26 00:08:20)
Cardinality 0 … 1
Concept inherits from draft 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
max length
150
target Used by one transaction, 0 templates, inherited 0 times
 
draft Specialty 0 … 1
prsb03-dataelement-14221
Id prsb03-dataelement-14221 (2021‑02‑26 00:08:20)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13911 (2021‑02‑02 22:47:46)
Description The main specialty of the person completing the record.

Properties

FHIR PractitionerRole.specialty
Rationale PractitionerRole.specialty
Operationalization NHS data dictionary :- Activity treatment function code
Value Domain
Property
max length
3
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft Organisation 0 … 1
prsb03-dataelement-14222
Id prsb03-dataelement-14222 (2021‑02‑26 00:08:20)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13912 (2021‑02‑02 22:55:15)
Description The organisation the person completing the record works for.
target Used by one transaction, 0 templates, inherited 0 times
 
draft Coded value 0 … 1
prsb03-dataelement-14223
Id prsb03-dataelement-14223 (2021‑02‑26 00:08:20)
Cardinality 0 … 1
Concept inherits from draft 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
target Used by one transaction, 0 templates, inherited 0 times
 
draft Free text 0 … 1
prsb03-dataelement-14224
Id prsb03-dataelement-14224 (2021‑02‑26 00:08:20)
Cardinality 0 … 1
Concept inherits from draft 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
max length
150
target Used by one transaction, 0 templates, inherited 0 times
 
draft Professional identifier 0 … 1
prsb03-dataelement-14225
Id prsb03-dataelement-14225 (2021‑02‑26 00:08:20)
Cardinality 0 … 1
Concept inherits from draft 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.

Properties

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
max length
32
target Used by one transaction, 0 templates, inherited 0 times
 
draft Date completed 0 … 1
prsb03-dataelement-14226
Id prsb03-dataelement-14226 (2021‑02‑26 00:08:20)
Cardinality 0 … 1
Concept inherits from draft 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
target Used by one transaction, 0 templates, inherited 0 times
 
draft Contact details 0 … 1
prsb03-dataelement-14227
Id prsb03-dataelement-14227 (2021‑02‑26 00:08:20)
Cardinality 0 … 1
Concept inherits from draft 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.).

Properties

FHIR PractitionerRole.telecom
Rationale Practitioner.telecom



PractitionerRole.telecom



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