Care Home

Version 2.2

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Info
MROInfo
Information
TypeInfo
Name
Description
Value SetsInfo
Implementation
GuidanceInfo
CardinalityInfo
MRO: M
Information type:
Name: Person demographics
Description:
The person's details and contact information.
Valueset:
-
Cardinality: 1 ... 1
MRO: M
Information type:
Name: Person name
Description:
Details of the person's name
Valueset:
-
Cardinality: 1 ... 1
MRO: R
Information type:
Name: Person first name
Description:
The first name(s) of the person. This includes middle names.
Valueset:
NHS data dictionary :- Person given name
Cardinality: 0 ... *
MRO: R
Information type:
Name: Person family name
Description:
The family name or surname of the person
Valueset:
NHS data dictionary : - Person family name
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Person preferred name
Description:
The name by which a person wishes to be addressed. The preferred name volunteered by the person or a preferred name given by PDS that the person has asked to be called by.
Valueset:
NHS data dictionary: - Person full name
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Title
Description:
Person's title
Valueset:
NHS data dictionary: - Person title
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Person name suffix
Description:
A textual suffix that may be added to the end of a PERSON's name, for example, OBE, MBE, BSc, JP, GM
Valueset:
NHS data dictionary: - Person suffix
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Person full name
Description:
The full name of the person in text representation.
Valueset:
NHS data dictionary :- Patient full name
Cardinality: 0 ... 1
MRO: M
Information type:
Name: Date of birth
Description:
The date of birth of the person.
Valueset:
NHS data dictionary:- Person birth date
Cardinality: 1 ... 1
MRO: R
Information type:
Name: Gender
Description:
The person's stated gender.
Valueset:
NHS data dictionary :- Person stated gender code
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Ethnicity
Description:
The ethnicity of the person as specified by the person.
Valueset:
NHS data dictionary :- Ethnic category
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Religion
Description:
The religious affiliation as specified by the person.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Sex
Description:
The person’s phenotypic sex. Determines how the person will be treated clinically.
Valueset:
Cardinality: 0 ... 1
MRO: R
Information type:
Name: NHS number
Description:
The unique identifier for a person within the NHS in England and Wales.
Valueset:
NHS data dictionary:- NHS number
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Other identifier
Description:
Country specific or local identifier, e.g. Community Health Index (CHI) in Scotland.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Person's address
Description:
Person’s usual place of residence, and where relevant temporary and correspondence addresses.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Address line 1
Description:
Person's first line of address.
Valueset:
NHS data dictionary :-  Address line 1
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Address line 2
Description:
Person's second line of address.
Valueset:
NHS data dictionary :- Address line 2
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Address line 3
Description:
Person's third line of address.
Valueset:
NHS data dictionary : - Address line 3
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Address line 4
Description:
Person's fourth line of address.
Valueset:
NHS data dictionary : - Address line 4
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Address line 5
Description:
Person's fifth line of address.
Valueset:
NHS data dictionary : - Address line 5
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Postcode
Description:
The person's postcode.
Valueset:
NHS data dictionary :- Postcode of usual address
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Place of birth
Description:
The country of birth of the person.
Valueset:
NHS data dictionary :- Country code (birth)
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Organ and tissue donation
Description:
Whether the person has given consent for organ and/or tissue donation or opted out of automatic donation where applicable. This is information provided by the national register.
Valueset:
Flag: - Yes or No
Cardinality: 0 ... 1
MRO: R
Information type:
Name: GP practice
Description:
Details of the person's GP practice.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: GP practice record entry
Description:
This is an GP practice record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items
Valueset:
-
Cardinality: 0 ... *
MRO: R
Information type:
Name: GP name
Description:
The name of the person's GP. If the person is registered with a GP practice, their usual GP name will be something volunteered by the person or their representative.
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: GP practice details
Description:
Name and address of the person's registered GP practice Registered GP practice details are available from the Patient Demographics Service (PDS), or volunteered from the person or their representative. Include details of the practice name and address.
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: GP practice identifier
Description:
The identifier of the registered GP practice.
Valueset:
Cardinality: 0 ... 1
MRO: R
Information type:
Name: About me
Description:
About me
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: About me
Description:
This is a record of the things that a person feels it is important to communicate about their needs, strengths, values, concerns and preferences to others providing support and care.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: What is most important to me
Description:
A description of what is most important to you
Emergency Information : - Include any essential information that any professional in health and social care should know about the you in any situation, including emergencies.
Other Information : -This could include : - Values, Spirituality/religion, Ethnicity, Culture, Pets, Goals and aspirations, Meaningful activities including leisure activities, visiting places, sport and exercise, listening to music, employment, education, volunteering
Valueset:
Free text or multimedia file
Cardinality: 0 ... 1
MRO: R
Information type:
Name: People who are important to me
Description:
 Details of who is important to you and why. They could be family members, carers, friends, members of staff etc. Include how you want the people important to you to be engaged and involved in your care and support in both emergency and normal situations. Include how you stay connected to the people important to you. Who should not be contacted or consulted about your care and support and why, if you wish to say
Valueset:
Free text or multimedia file
Cardinality: 0 ... 1
MRO: R
Information type:
Name: How I communicate and how to communicate with me
Description:

A description of how you communicate normally including any communication aids you use, for example a hearing aid.

  • Include your preferred language of communication, if your first language is not English.
  • Include how you would communicate when you are in pain or distress.
  • Include how you communicate choices.
  • Include how you give feedback or raise a concern.
  • Include how you like to receive information

Describe how you would like others to engage and communicate with you, including how you would like to be addressed.

Valueset:
Free text or multimedia file
Cardinality: 0 ... 1
MRO: R
Information type:
Name: My wellness
Description:

A description covering what you are able to do, how you engage with others and how you feel on a typical day through to on a day when you are unwell or really unwell.

  • Include any causes that might result in you becoming unwell and strategies for avoiding or addressing the causes. For example, not drinking enough water could cause constipation.
  • Include any signs that indicate you might be becoming unwell.
  • On a bad day describe what is different about what you are able to do, how you engage with others and how you feel.
  • Include how your everyday life is affected by any medical conditions e.g. dementia and any symptoms e.g. itchiness, cough, pain and how you manage those conditions.
  • Include past health issues or experiences that need to be considered
  • Include your wellbeing and lifestyle goals and aspirations
Valueset:
Free text or multimedia file
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Please do and please don't
Description:

A description of things you want someone supporting you to do or not to do.

For example, this might include: - Talk to me not to my carer, remind me to take my medication, encourage me to wash my hands regularly, explain to me what is happening and why, respond to my communication.

A description of things you do not want someone supporting for you to do. For example, this might include: - Discussing or asking questions about certain topics, making assumptions about something, providing support when it is not wanted, talking to you in a certain way.

Valueset:
Free text or multimedia file
Cardinality: 0 ... 1
MRO: R
Information type:
Name: How and when to support me
Description:

A description of how and when you want someone caring for you to support you.

This could include support needs in an emergency situation (for example taking blood)

This could include support you need to maintain important routines or to carry out particular activities, for example: - Personal care routines, Eating and drinking, Bedtime routines, Taking medications, Moving and transitioning

This could also include support needed with:- wearing glasses/hearing aids/false teeth etc, making informed choices or understanding dangers and risks, managing your emotions, moods and behaviours, memory or confusion.

Include how your support needs change in different environments. Include any triggers that might result in you needing further support and strategies for avoiding or addressing the triggers. Include how you want the support to be provided.

Valueset:
Free text or multimedia file
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Also worth knowing about me
Description:

A description of what is also worth knowing about you for people caring or supporting you.

This could include a short history of your life (where you have worked, where you lived, important events in your life, important people in your past life).

This could include a short profile of your current life:- your work / study, your aspirations, your skills, your networks, things you like e.g. particular foods, places, a football team and things you like to talk about, things you dislike

This could also include any care and support preferences that have not been included elsewhere.

Valueset:
Free text or multimedia file
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Date
Description:
This is a record of the date that this information was last updated.
Valueset:
Date and Time
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Supported to write this by
Description:
Where relevant, this is a record of name, relationship/role and contact details of the individual who supported the person to write this section e.g. carer, family member, advocate, professional.
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Individual requirements
Description:
The individual requirements of the person.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Reasonable adjustment
Description:
A record of reasonable adjustments that must be provided by the service to comply with the Equality Act 2010.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Reasonable adjustment record entry
Description:
This is a reasonable adjustment record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Location
Description:
The location where the reasonable adjustment was identified.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Coded value
Description:
The coded value for location.
Valueset:
NHS Data dictionary : - Organisation data service code
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Free text
Description:
Free text field to be used if no code is available
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Reasonable adjustment flag
Description:

Under the Equality Act 2010, organisations have a legal duty to make changes in their approach or provision to ensure that services are as accessible to people with disabilities as they are for everybody else. These changes are called reasonable adjustments.

Reasonable adjustments can mean alterations to buildings by providing lifts, wide doors, ramps and tactile signage, but may also mean changes to policies, procedures and staff training to ensure that services work equally well for people with physical or sensory disabilities, learning disabilities or long-term conditions such as dementia.

Other adjustments include longer appointments, providing easy read materials or communications via a carer. This legal duty is anticipatory which means a service should know about a person’s need for adjustments when they are referred or present for care. For this to happen, and for optimum care to be delivered, adjustments need to be recorded and shared across the NHS.

Valueset:
SNOMED CT: - 1108111000000107 |Requires reasonable adjustments for health and care access (Equality Act 2010) (finding)|
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Reasonable adjustment
Description:
The reasonable adjustment required e.g. requires specific contact method, requires communication professional
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Coded value
Description:
The coded value for reasonable adjustment
Valueset:
SNOMED CT : - Accessible information standard
^999002121000000109 |Accessible information - communication support simple reference set (foundation metadata concept)|
^999002151000000104 |Accessible information - requires communication professional simple reference set (foundation metadata concept)|
^999002131000000106 |Accessible information - requires specific contact method simple reference set (foundation metadata concept)|
^999002141000000102 |Accessible information - requires specific information format simple reference set (foundation metadata concept)|
Refsets for other categories in development
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Free text
Description:
Free text field to be used if no code is available
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Reasonable adjustment additional detail
Description:
Further detail about the support required and the consequence of not providing it.
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Date
Description:
The date the reasonable adjustment was identified.
Valueset:
Date and time
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Performing professional
Description:
The professional who confirmed the need for the reasonable adjustment.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Name
Description:
The name of the professional.
Valueset:
Free text.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Role
Description:
The role the professional has in relation to the person.
Valueset:
FHIR value set : - sdsjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Grade
Description:
The grade of the professional.
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Speciality
Description:
The specialty of the professional.
Valueset:
NHS data dictionary - Main specialty code
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Professional identifier
Description:
Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.
Valueset:
NHS data dictionary : - Professional registration identifier
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Organisation
Description:
The name of the organisation the professional works for.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Contact details
Description:
Contact details of the professional
Valueset:
NHS data dictionary - UK phone number
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Person completing record
Description:
A record of the details of the person that entered the reasonable adjustment and the date on which it was entered.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Name
Description:
The name of the person completing the record.
Valueset:
Free text.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Role
Description:
The organisational role of the person completing record.
Valueset:
FHIR value set :- SDSjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Grade
Description:
The grade of the person completing the record.
Valueset:
Free text.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Specialty
Description:
The main specialty of the person completing the record.
Valueset:
NHS data dictionary :- Activity treatment function code
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Organisation
Description:
The organisation the person completing the record works for.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Professional identifier
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.
Valueset:
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Date completed
Description:
The date and time the record was completed.
Valueset:
Date and time.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Contact details
Description:
Contact details of the person completing the record.
Valueset:
NHS data dictionary : - UK telephone number
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Impairment
Description:
A record of any impairments for the person relating to reasonable adjustments.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Impairment record entry
Description:
This is an impairment record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Location
Description:
The location where the impairment was identified.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Coded value
Description:
The coded value for location.
Valueset:
NHS data dictionary: - Organisation code service
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Free text
Description:
Free text field to be used if no code is available
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Impairment category
Description:
The category of the impairment e.g. Autism, Dementia, Physical disability, Sensory disability - such as sight or hearing, Long-term condition
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Coded value
Description:
The coded value for impairment.
Valueset:
SNOMED CT
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Free text
Description:
Free text field to be used if no code is available
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Impairment additional detail
Description:

Description of what the person can do with the impairment, what they want to be able to do and how they should be supported to do it and what the consequences are of not providing the support.
Where there is a sensory disability include sensory processing difficulties (e.g. affects to balance and movement, oversensitive, under-sensitive).
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Date
Description:
The date the impairment was identified.
Valueset:
Date and time
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Performing professional
Description:
The professional who confirmed the impairment.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Name
Description:
The name of the professional.
Valueset:
Free text.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Role
Description:
The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc
Valueset:
FHIR value set :- SDSjobroletype
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Grade
Description:
The grade of the professional.
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Speciality
Description:
The specialty of the professional e.g. physiotherapy, oncology, mental health etc
Valueset:
NHS data dictionary - Activity treatment function code
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Professional identifier
Description:
Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.
Valueset:
NHS data dictionary : - Professional registration identifier
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Organisation
Description:
The name of the organisation the professional works for.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Contact details
Description:
Contact details of the professional
Valueset:
NHS data dictionary - UK phone number
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Person completing record
Description:

A record of the details of the person that entered the impairment and the date on which it was entered.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Name
Description:
The name of the person completing the record.
Valueset:
Free text.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Role
Description:
The organisational role of the person completing record.
Valueset:
FHIR value set :- SDSjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Grade
Description:
The grade of the person completing the record.
Valueset:
Free text.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Specialty
Description:
The main specialty of the person completing the record.
Valueset:
NHS data dictionary :- Activity treatment function code
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Organisation
Description:
The organisation the person completing the record works for.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Professional identifier
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.
Valueset:
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Date completed
Description:
The date and time the record was completed.
Valueset:
Date and time.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Contact details
Description:
Contact details of the person completing the record.
Valueset:
NHS data dictionary : - UK telephone number
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Mobility
Description:
Details of the person's mobility needs.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Date
Description:
The date when the mobility needs were identified.
Valueset:
Date and time
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Location
Description:
The location where the mobility needs were identified.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Coded value
Description:
The coded value for location.
Valueset:
NHS data dictionary : - Organisation data service
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Free text
Description:
Free text field to be used if no coded text available
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Mobility needs
Description:
The mobility needs of the person that allows movement between two spaces and achieves participation and a degree of independence.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Coded value
Description:
The coded value for mobility needs
Valueset:
SNOMED CT: - ^999002551000000108 |Mobility findings simple reference set (foundation metadata concept)|
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Free text
Description:
Free text field to be used if no code is available
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Performing professional
Description:
The professional who identified the mobility needs.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Name
Description:
The name of the professional.
Valueset:
Free text.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Role
Description:
The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc
Valueset:
FHIR value set :- SDSjobroletype
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Grade
Description:
The grade of the professional.
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Speciality
Description:
The specialty of the professional e.g. physiotherapy, oncology, mental health etc
Valueset:
NHS data dictionary - Activity treatment function code
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Professional identifier
Description:
Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.
Valueset:
NHS data dictionary : - Professional registration identifier
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Organisation
Description:
The name of the organisation the professional works for.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Contact details
Description:
Contact details of the professional
Valueset:
NHS data dictionary - UK phone number
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Person completing record
Description:
Details of the person completing the record.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Name
Description:
The name of the person completing the record.
Valueset:
Free text.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Role
Description:
The organisational role of the person completing record.
Valueset:
FHIR value set :- SDSjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Grade
Description:
The grade of the person completing the record.
Valueset:
Free text.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Specialty
Description:
The main specialty of the person completing the record.
Valueset:
NHS data dictionary :- Activity treatment function code
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Organisation
Description:
The organisation the person completing the record works for.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Professional identifier
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.
Valueset:
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Date completed
Description:
The date and time the record was completed.
Valueset:
Date and time.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Contact details
Description:
Contact details of the person completing the record.
Valueset:
NHS data dictionary : - UK telephone number
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Other individual requirements
Description:
Details of any other individual requirements the person may have
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Date
Description:
The date when the other individual requirements were identified.
Valueset:
Date and time
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Location
Description:
The location where the other individual requirements were identified.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Coded value
Description:
The coded value for location.
Valueset:
NHS data dictionary : - Organisation service code
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Free text
Description:
Free text field to be used if no coded text available
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Other individual requirement
Description:
Other individual requirements that a person may have.
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Performing professional
Description:
The professional who identified the other individual requirements.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Name
Description:
The name of the professional.
Valueset:
Free text.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Role
Description:
The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc
Valueset:
FHIR value set :- SDSjobroletype
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Grade
Description:
The grade of the professional.
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Speciality
Description:
The specialty of the professional e.g. physiotherapy, oncology, mental health etc
Valueset:
NHS data dictionary - Activity treatment function code
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Professional identifier
Description:
Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.
Valueset:
NHS data dictionary : - Professional registration identifier
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Organisation
Description:
The name of the organisation the professional works for.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Contact details
Description:
Contact details of the professional
Valueset:
NHS data dictionary - UK phone number
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Person completing record
Description:
Details of the person completing the record.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Name
Description:
The name of the person completing the record.
Valueset:
Free text.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Role
Description:
The organisational role of the person completing record.
Valueset:
FHIR value set :- SDSjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Grade
Description:
The grade of the person completing the record.
Valueset:
Free text.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Specialty
Description:
The main specialty of the person completing the record.
Valueset:
NHS data dictionary :- Activity treatment function code
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Organisation
Description:
The organisation the person completing the record works for.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Professional identifier
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.
Valueset:
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Date completed
Description:
The date and time the record was completed.
Valueset:
Date and time.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Contact details
Description:
Contact details of the person completing the record.
Valueset:
NHS data dictionary : - UK telephone number
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Alerts
Description:
Details of alerts.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Alerts record entry
Description:
This is an alerts 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
Valueset:
-
Cardinality: 0 ... *
MRO: R
Information type:
Name: Alert
Description:
Any significant information meriting a specific and highly visible warning to any user (e.g. metallic implant, potential dangerous pet).
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Person completing record
Description:
Details of the person completing the record.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Name
Description:
The name of the person completing the record.
Valueset:
Free text.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Role
Description:
The organisational role of the person completing record.
Valueset:
FHIR value set :- SDSjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Grade
Description:
The grade of the person completing the record.
Valueset:
Free text.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Specialty
Description:
The main specialty of the person completing the record.
Valueset:
NHS data dictionary :- Activity treatment function code
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Organisation
Description:
The organisation the person completing the record works for.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Professional identifier
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.
Valueset:
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Date completed
Description:
The date and time the record was completed.
Valueset:
Date and time.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Contact details
Description:
Contact details of the person completing the record.
Valueset:
NHS data dictionary : - UK telephone number
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Legal information
Description:
The legal information relating to the person.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Mental capacity assessment
Description:
Details of the persons mental capacity assessment
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Date
Description:
The date when the mental capacity assessment was made.
Valueset:
Date and time
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Location
Description:
The location where the mental capacity assessment was made.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Coded value
Description:
The coded value for location
Valueset:
NHS data dictionary : - Organisation code
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Free text
Description:
Free text field to be used if no code is available
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Mental capacity assessment
Description:
Whether an assessment of the mental capacity of the (adult) person has been undertaken, if so, what capacity the decision relates to and the outcome of the assessment. Also record best interests decision if person lacks capacity.
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Location of document
Description:
The location of the mental capacity assessment information.
Valueset:
Free text or URL
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Performing professional
Description:
The professional who made the mental capacity assessment.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Name
Description:
The name of the professional.
Valueset:
Free text.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Role
Description:
The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc
Valueset:
FHIR value set :- SDSjobroletype
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Grade
Description:
The grade of the professional.
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Speciality
Description:
The specialty of the professional e.g. physiotherapy, oncology, mental health etc
Valueset:
NHS data dictionary - Activity treatment function code
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Professional identifier
Description:
Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.
Valueset:
NHS data dictionary : - Professional registration identifier
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Organisation
Description:
The name of the organisation the professional works for.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Coded value
Description:
The coded value for location
Valueset:
NHS data dictionary: - Organisation data service
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Free text
Description:
Free text field to be used if no code is available
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Contact details
Description:
Contact details of the professional
Valueset:
NHS data dictionary - UK phone number
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Person completing record
Description:
Details of the person completing the record.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Name
Description:
The name of the person completing the record.
Valueset:
Free text.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Role
Description:
The organisational role of the person completing record.
Valueset:
FHIR value set :- SDSjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Grade
Description:
The grade of the person completing the record.
Valueset:
Free text.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Specialty
Description:
The main specialty of the person completing the record.
Valueset:
NHS data dictionary :- Activity treatment function code
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Organisation
Description:
The organisation the person completing the record works for.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Coded value
Description:
The coded value for location
Valueset:
NHS data dictionary : - Organisation data service
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Free text
Description:
Free text field to be used if no code is available
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Professional identifier
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.
Valueset:
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Date completed
Description:
The date and time the record was completed.
Valueset:
Date and time.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Contact details
Description:
Contact details of the person completing the record.
Valueset:
NHS data dictionary : - UK telephone number
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Lasting power of attorney for personal welfare or court-appointed deputy (or equivalent)
Description:
Details of the person's LPA record or equivalent
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Date
Description:
The date the LPA was recorded
Valueset:
Date and time
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Location
Description:
The location where the LPA was given
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Coded value
Description:
The coded value for location
Valueset:
NHS data dictionary : - Organisation code

Cardinality: 0 ... 1
MRO: R
Information type:
Name: Free text
Description:
Free text field to be used if no code is available
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Lasting power of attorney for personal welfare or court appointed deputy (or equivalent)
Description:
Record of one or more people who have been given power (LPA) by the person when they had capacity to make decisions about their health and welfare should they lose capacity to make those decisions. To be valid, an LPA must have been registered with the Court of Protection. If life-sustaining treatment is being considered the LPA document must state specifically that the attorney has been given power to consent to or refuse life-sustaining treatment. Details of any person (deputy) appointed by the court to make decisions about the person’s health and welfare. A deputy does not have the power to refuse life-sustaining treatment.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Coded value
Description:
The coded value for the LPA
Valueset:
SNOMED CT: - ^999001951000000107 |Personal welfare lasting power of attorney findings simple reference set (foundation metadata concept)|
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Location of document
Description:
The location of the LPA information
Valueset:
Free text or URL
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Name of LPA
Description:
The names of any appointed people or deputies
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Contact details
Description:
The contact details of the LPA
Valueset:
NHS data dictionary:- UK telephone number
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Performing professional
Description:
The professional who took the details of the LPA or equivalent
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Name
Description:
The name of the professional.
Valueset:
Free text.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Role
Description:
The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc
Valueset:
FHIR value set :- SDSjobroletype
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Grade
Description:
The grade of the professional.
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Speciality
Description:
The specialty of the professional e.g. physiotherapy, oncology, mental health etc
Valueset:
NHS data dictionary - Activity treatment function code
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Professional identifier
Description:
Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.
Valueset:
NHS data dictionary : - Professional registration identifier
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Organisation
Description:
The name of the organisation the professional works for.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Contact details
Description:
Contact details of the professional
Valueset:
NHS data dictionary - UK phone number
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Person completing record
Description:
Details of the person who took the LPA.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Name
Description:
The name of the person completing the record.
Valueset:
Free text.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Role
Description:
The organisational role of the person completing record.
Valueset:
FHIR value set :- SDSjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Grade
Description:
The grade of the person completing the record.
Valueset:
Free text.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Specialty
Description:
The main specialty of the person completing the record.
Valueset:
NHS data dictionary :- Activity treatment function code
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Organisation
Description:
The organisation the person completing the record works for.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Professional identifier
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.
Valueset:
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Date completed
Description:
The date and time the record was completed.
Valueset:
Date and time.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Contact details
Description:
Contact details of the person completing the record.
Valueset:
NHS data dictionary : - UK telephone number
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Deprivation of Liberty Safeguards or equivalent
Description:
Details of the person's Deprivation of Liberty Safeguards (DoLS) or equivalent
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Application date
Description:
The date the application was made
Valueset:
Date and time
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Application status
Description:
The status of the DOLs application.
Valueset:
Free text : - Requested or authorised
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Deprivation of liberty safeguards or equivalent
Description:
Record of Deprivation of Liberty Safeguards (DoLS) or equivalent, including the reason for this.
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Start date of authorisation
Description:
The date the DOLs was authorised.
Valueset:
Data and time
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Planned or actual end date of authorisation
Description:
The planned or actual end date of authorisation.
Valueset:
Date and time
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Performing professional
Description:
The professional who applied for the DOLs.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Name
Description:
The name of the professional.
Valueset:
Free text.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Role
Description:
The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc
Valueset:
FHIR value set :- SDSjobroletype
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Grade
Description:
The grade of the professional.
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Speciality
Description:
The specialty of the professional e.g. physiotherapy, oncology, mental health etc
Valueset:
NHS data dictionary - Activity treatment function code
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Professional identifier
Description:
Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.
Valueset:
NHS data dictionary : - Professional registration identifier
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Organisation
Description:
The name of the organisation the professional works for.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Contact details
Description:
Contact details of the professional
Valueset:
NHS data dictionary - UK phone number
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Mental health act or equivalent status
Description:
Details of the persons mental health act record
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Section start date
Description:
The date the person was detained.
Valueset:
Date and time
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Section end date
Description:
The date the person was no longer detained.
Valueset:
Date and time
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Location
Description:
The location where the decision to detain the person was made under the mental health act.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Coded value
Description:
The coded value for location
Valueset:
NHS data dictionary : - Organisation code

Cardinality: 0 ... 1
MRO: R
Information type:
Name: Free text
Description:
Free text field to be used if no code is available
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Mental health act or equivalent status
Description:
Record where a person diagnosed with a mental disorder is formally detained under the Mental health act or equivalent, including the section number. If person subject to Community Treatment Order or Conditional Discharge (or equivalent) record here.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Coded value
Description:
The coded value for mental health act
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Free text
Description:
Free text field to be used if no code is available
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Supporting information
Description:
If person subject to Community Treatment Order or Conditional Discharge (or equivalent) record here.
Valueset:
NHS data dictionary : - Community treatment order
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Performing professional
Description:
The professional who made the decision to detain the person under the mental health act.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Name
Description:
The name of the professional.
Valueset:
Free text.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Role
Description:
The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc
Valueset:
FHIR value set :- SDSjobroletype
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Grade
Description:
The grade of the professional.
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Speciality
Description:
The specialty of the professional e.g. physiotherapy, oncology, mental health etc
Valueset:
NHS data dictionary - Activity treatment function code
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Professional identifier
Description:
Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.
Valueset:
NHS data dictionary : - Professional registration identifier
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Organisation
Description:
The name of the organisation the professional works for.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Contact details
Description:
Contact details of the professional
Valueset:
NHS data dictionary - UK phone number
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Person completing record
Description:
Details of the person completing the record.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Name
Description:
The name of the person completing the record.
Valueset:
Free text.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Role
Description:
The organisational role of the person completing record.
Valueset:
FHIR value set :- SDSjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Grade
Description:
The grade of the person completing the record.
Valueset:
Free text.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Specialty
Description:
The main specialty of the person completing the record.
Valueset:
NHS data dictionary :- Activity treatment function code
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Organisation
Description:
The organisation the person completing the record works for.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Professional identifier
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.
Valueset:
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Date completed
Description:
The date and time the record was completed.
Valueset:
Date and time.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Contact details
Description:
Contact details of the person completing the record.
Valueset:
NHS data dictionary : - UK telephone number
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Advance decision to refuse treatment (ADRT)
Description:
Details of the person's ADRT status.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Date
Description:
The date the ADRT was recorded.
Valueset:
Date
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Location
Description:
The location where the ADRT was recorded.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Coded value
Description:
The coded value of location
Valueset:
NHS data dictionary : - Organisation data service
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Free text
Description:
Free text field to be used if no coded text available
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Advance decision to refuse treatment
Description:
A record of an advance decision to refuse one or more specific types of future treatment, made by a person who had capacity at the time of recording the decision. The decision only applies when the person no longer has the capacity to consent to or refuse the specific treatment being considered. An ADRT must be in writing, signed and witnessed. If the ADRT is refusing life-sustaining treatment it must state specifically that the treatment is refused even if the person’s life is at risk.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Coded value
Description:
The coded value for advance decision to refuse treatment.
Valueset:
SNOMED CT:- ^999002181000000105 |Advance decision to refuse treatment preference findings simple reference set (foundation metadata concept)|
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Free text
Description:
Free text field to be used if no code is available
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Performing professional
Description:
The professional who recorded the ADRT
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Name
Description:
The name of the professional.
Valueset:
Free text.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Role
Description:
The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc
Valueset:
FHIR value set :- SDSjobroletype
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Grade
Description:
The grade of the professional.
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Speciality
Description:
The specialty of the professional e.g. physiotherapy, oncology, mental health etc
Valueset:
NHS data dictionary - Activity treatment function code
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Professional identifier
Description:
Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.
Valueset:
NHS data dictionary : - Professional registration identifier
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Organisation
Description:
The name of the organisation the professional works for.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Contact details
Description:
Contact details of the professional
Valueset:
NHS data dictionary - UK phone number
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Person completing record
Description:
Details of the person who recorded the ADRT.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Name
Description:
The name of the person completing the record.
Valueset:
Free text.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Role
Description:
The organisational role of the person completing record.
Valueset:
FHIR value set :- SDSjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Grade
Description:
The grade of the person completing the record.
Valueset:
Free text.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Specialty
Description:
The main specialty of the person completing the record.
Valueset:
NHS data dictionary :- Activity treatment function code
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Organisation
Description:
The organisation the person completing the record works for.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Professional identifier
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.
Valueset:
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Date completed
Description:
The date and time the record was completed.
Valueset:
Date and time.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Contact details
Description:
Contact details of the person completing the record.
Valueset:
NHS data dictionary : - UK telephone number
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Safeguarding
Description:
The safeguarding details of the person.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Safeguarding concerns
Description:
Details of safeguarding concerns
Valueset:
-
Cardinality: 0 ... *
MRO: R
Information type:
Name: Safeguarding concerns date
Description:
The date the safeguarding concerns were identified.
Valueset:
Date and time
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Safeguarding concerns end date
Description:
The date safeguarding concerns ended.
Valueset:
Date and time
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Location
Description:
The location where the safeguarding concerns were identified.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Coded value
Description:
The coded value of location
Valueset:
NHS data dictionary : - Organisation code
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Free text
Description:
Free text field to be used if no code is available
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Safeguarding concerns
Description:
Identified safeguarding concerns.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Coded value
Description:
The coded value for safeguarding concerns
Valueset:
SNOMED CT : - 999002381000000108 | Safeguarding issues simple reference set (foundation metadata concept) |
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Free text
Description:
Free text field to be used if no code is available
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Performing professional
Description:
The professional who identified the safeguarding concerns.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Name
Description:
The name of the professional.
Valueset:
Free text.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Role
Description:
The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc
Valueset:
FHIR value set :- SDSjobroletype
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Grade
Description:
The grade of the professional.
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Speciality
Description:
The specialty of the professional e.g. physiotherapy, oncology, mental health etc
Valueset:
NHS data dictionary - Activity treatment function code
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Professional identifier
Description:
Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.
Valueset:
NHS data dictionary : - Professional registration identifier
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Organisation
Description:
The name of the organisation the professional works for.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Contact details
Description:
Contact details of the professional
Valueset:
NHS data dictionary - UK phone number
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Person completing record
Description:
Details of the person completing the record.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Name
Description:
The name of the person completing the record.
Valueset:
Free text.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Role
Description:
The organisational role of the person completing record.
Valueset:
FHIR value set :- SDSjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Grade
Description:
The grade of the person completing the record.
Valueset:
Free text.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Specialty
Description:
The main specialty of the person completing the record.
Valueset:
NHS data dictionary :- Activity treatment function code
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Organisation
Description:
The organisation the person completing the record works for.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Professional identifier
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.
Valueset:
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Date completed
Description:
The date and time the record was completed.
Valueset:
Date and time.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Contact details
Description:
Contact details of the person completing the record.
Valueset:
NHS data dictionary : - UK telephone number
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Comment
Description:
Further details on safeguarding concerns.
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Professional contacts
Description:
The details of the person’s professional contacts.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Professional contacts record entry
Description:
This is a professional contacts record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
Valueset:
-
Cardinality: 0 ... *
MRO: R
Information type:
Name: Name
Description:
The name of the professional with responsibility for the care of the person.
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Role
Description:
The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker, key worker, care home manager, care coordinator, LA hospital liaison person, care home contact, hospital clinician, Independent Mental Capacity Advocate (IMCA) etc
Valueset:
FHIR value set : - SDSjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Key worker
Description:
A flag that identifies the personal contact is the key worker assigned to the person.
Valueset:
Flag : - Yes or No
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Speciality
Description:
The specialty of the professional e.g. physiotherapy, oncology, mental health etc
Valueset:
NHS data dictionary : - Activity treatment function code
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Team
Description:
The name of the team.
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Organisation
Description:
The name of the organisation.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Coded value
Description:
The coded value for location
Valueset:
NHS data dictionary : - Organisation data service
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Free text
Description:
Free text field to be used if no code is available
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Contact details
Description:
Contact details of the professional (e.g. telephone number, email address etc.).
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Start date
Description:
The start date of the professional relationship with the person.
Valueset:
Date and time
Cardinality: 0 ... 1
MRO: R
Information type:
Name: End date
Description:
The end date of the professional relationship with the person.
Valueset:
Date and time
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Personal contacts
Description:
The details of the individual's personal contacts.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Personal contacts record entry
Description:
This is personal contacts record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
Valueset:
-
Cardinality: 0 ... *
MRO: R
Information type:
Name: Name
Description:
The name of the personal contact.
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Relationship
Description:
The relationship the personal contact has to the person, e.g. father, grandmother, family friend etc.
Valueset:
FHIR value set : - Related person
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Relationship type
Description:
Additional roles the person performs on behalf of the other (e.g. Carer, Next of Kin, Emergency Contact, Dependent, etc.)
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Contact details
Description:
Contact details of the personal contact (e.g. telephone number, email address etc.)
Valueset:
Free Text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Comments
Description:
Notes on the significance of the personal contact to the person.
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Referral details
Description:
The details of the referral.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Referral details record entry
Description:
This is the referral details record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
Valueset:
-
Cardinality: 0 ... *
MRO: R
Information type:
Name: Date
Description:
The date of referral
Valueset:
Date and time
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Referrer details
Description:
The details of the referrer.

This could be the person, GP surgery, department, specialty, sub-specialty, educational institution, mental health team etc.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Name
Description:
The name of the referrer.
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Role
Description:
Role of the referrer.
Valueset:
FHIR value set : - sdsjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Grade
Description:
The grade of the referrer.
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Team
Description:
The team or department of the referrer.
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Specialty
Description:
The specialty of the referrer.
Valueset:
NHS data dictionary - Activity treatment function code
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Service
Description:
The service of the referrer.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Coded value
Description:
The coded value for service
Valueset:
SNOMED CT: - 1127531000000102 |Services simple reference set (foundation metadata concept)|
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Free text
Description:
Free text field to be used if no code is available
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Organisation
Description:
The organisation of the referrer.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Coded value
Description:
The coded value for organisation code
Valueset:
NHS data dictionary : - Organisation data service
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Free text
Description:
Free text field to be used if no code is available
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Contact details
Description:
The contact details of the referrer.
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Referral method
Description:
The method in which a referral is sent and received. This may be a letter, email, transcript of a telephone conversation, Choose and Book, in person (self-referral) etc.
Valueset:
Allow National Codes only
  1. Fax
  2. Phone
  3. Secure Messaging
  4. Secure Email
  5. Letter
  6. NHS E-Referral Service
  7. Self referral
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Reason for referral
Description:
The reason for the referral, e.g. diagnosis, treatment, transfer of care due to relocation, investigation, second opinion, management of the patient (e.g. palliative care), or carer's concerns.
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Clinical urgency of referral
Description:
The details of the clinical urgency of referral
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Reason for urgency of referral
Description:
The reason for urgency of referral if not routine.
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Referral to
Description:
Details of where the referral is to be sent.

If not an individual, this could be a service, e.g. GP surgery, department, specialty, subspecialty, educational institution, mental health etc.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Name
Description:
Name of person the referral is to be sent to.
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Role
Description:
Role of person where the referral is to be sent to.
Valueset:
FHIR value set : - sdsjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Grade
Description:
The grade of the person where the referral is sent to.
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Team
Description:
The team or department of the person where the referral is being sent to
Valueset:
Free text.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Specialty
Description:
The specialty the referral is being sent to e.g. physiotherapy, oncology, mental health etc
Valueset:
NHS data dictionary - Activity treatment function code
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Service
Description:
The service of where the referral is sent to.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Coded value
Description:
The coded value for service
Valueset:
SNOMED CT: - 1127531000000102 |Services simple reference set (foundation metadata concept)|
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Free text
Description:
Free text field to be used if no code is available
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Organisation
Description:
The organisation of where the referral is to be sent.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Coded value
Description:
The coded value for organisation
Valueset:
NHS data dictionary :- Organisation data service
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Free text
Description:
Free text field to be used if no code is available
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Contact details
Description:
The contact details of where the referral is to be sent.
Valueset:
Free text.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Referral criteria
Description:
Records whether specific criteria required for referral, to a particular service, have been met (may be nationally or locally determined). This field is used to outline which criteria have been met where a service has indicated specific criteria and to explain the rationale for referral where criteria have not been met.
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Return response to
Description:
Name of professional to be communicated with, if not the referrer
Valueset:
Free text.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Contacts with professionals
Description:
The details of the person’s contact with a professional.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Contacts with professionals record entry
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.
Valueset:
-
Cardinality: 0 ... *
MRO: R
Information type:
Name: Date of contact
Description:
Date and time of the contact.
Valueset:
Date and time.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Location of contact
Description:
The location where the contact took place.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Coded value
Description:
The coded value for location
Valueset:
NHS data dictionary : - Organisation service code
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Free text
Description:
Free text field to be used if no code is available
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Seen by
Description:
The professional that saw the person.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Name
Description:
The name of the professional that saw the person
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Role
Description:
The role of the person providing the service.
Valueset:
FHIR values set : - sdsjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Responsible professional
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).
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Name
Description:
The name of the responsible professional.
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Role
Description:
The role of the responsible professional
Valueset:
FHIR value set : - sdsjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Location type
Description:
The type of location where the contact took place e.g. person's home
Valueset:
NHS data dictionary - Activity location type code
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Contact type
Description:
Type of contact e.g. GP consultation, outpatient attendance
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Consultation method
Description:
Consultation method used e.g. face to face, telephone
Valueset:
NHS data dictionary - Consultation medium
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Specialty
Description:
The specialty e.g. physiotherapy, oncology, mental health etc
Valueset:
NHS data dictionary - Activity treatment function code
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Service
Description:
The service that was provided.
Valueset:
SNOMED CT :- 1127531000000102 |Services simple reference set (foundation metadata concept)|

Cardinality: 0 ... 1
MRO: R
Information type:
Name: Professionals present
Description:
The name, role of the additional individuals or team members including consultant(s), nurse consultant(s), allied health professional(s), social worker(s)
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Name
Description:
The name of the professional present
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Role
Description:
The role of the professional present.
Valueset:
FHIR value set : - sdsjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Outcome of contact
Description:
This records the outcome of the contact.
Valueset:
NHS data dictionary :- Attended or did not attend code
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Admission details
Description:
Admission details
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Admission details record entry
Description:
This is the admission details record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
Valueset:
-
Cardinality: 0 ... *
MRO: R
Information type:
Name: Date of admission
Description:
Date and time the person was admitted to hospital.
Valueset:
Date and time
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Admitted to
Description:
The hospital the person was admitted to.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Coded value
Description:
The coded value for admission to
Valueset:
NHS data dictionary : - Organisations code of provider
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Free text
Description:
Free text field to be used if no code is available
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Responsible care professional
Description:
The care professional who has overall responsibility for the person (may not actually see the person)
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Name
Description:
The name of the responsible care professional.
Valueset:
Free text.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Role
Description:
The role of the responsible consultant.
Valueset:
FHIR value set: - sdsjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Reason for admission
Description:
The health problems and issues experienced by the person that prompted the decision to admit to hospital e.g. chest pain, mental health crisis, blackout, fall, a specific procedure, intervention, investigation or treatment, non compliance with treatment.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Coded value
Description:
The coded value for reason for admission
Valueset:
SNOMED CT: - ^1127581000000103 |Health issues simple reference set|
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Free text
Description:
Free text field to be used if no code is available
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Admission method
Description:
How the person was admitted to hospital e.g. elective, emergency, maternity, transfer etc.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Coded value
Description:
The coded value for admission method
Valueset:
NHS data dictionary : - Admission method
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Free text
Description:
Free text field to be used if no code is available
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Legal status on admission
Description:
Whether the person was admitted as informal or formal/detained.
Valueset:
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Source of admission
Description:
Where the person was immediately prior to admission, e.g. usual place of residence, temporary place of residence, penal establishment.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Coded value
Description:
The coded value of source of admission
Valueset:
NHS data dictionary :- Source of admission
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Free text
Description:
Free text field to be used if no code is available
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Individual accompanying person
Description:
Details of the accompanying individual and the extent to which they have provided the information about the person.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Name
Description:
Name of individual accompanying person.
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Relationship
Description:
Relationship of individual accompanying the person.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Coded value
Description:
The coded value for relationship to person.
Valueset:
FHIR value set: - Relationship type
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Free text
Description:
Free text field to be used if no code is available
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Comment
Description:
Information about the extent to which the accompanying individual provided information about the person.
Valueset:
Free text.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Specialty
Description:
The specialty e.g. physiotherapy, oncology, mental health etc
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Coded value
Description:
The coded value for specialty
Valueset:
NHS data dictionary :- Activity treatment function code
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Free text
Description:
Free text field to be used if no code is available
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Discharge details
Description:
Discharge details
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Discharge details record entry
Description:
This is the discharge details record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
Valueset:
-
Cardinality: 0 ... *
MRO: R
Information type:
Name: Date of discharge
Description:
The date and time of discharge
Valueset:
Date and time
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Discharge location
Description:
The hospital the person was discharged from.
Valueset:
NHS data dictionary : - Organisation data service
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Discharging consultant
Description:
The consultant responsible for the person at time of discharge.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Name
Description:
The name of the discharging consultant
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Role
Description:
The role of the discharging consultant
Valueset:
FHIR value set : - sdsjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Discharge method
Description:
The method of discharge from hospital e.g. person discharged on clinical advice or with clinical consent; person discharged him/herself or was discharged by a relative or advocate.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Coded value
Description:
The coded value for discharge method
Valueset:
NHS data dictionary : - Discharge method
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Free text
Description:
Free text field to be used if no code is available
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Discharging specialty
Description:
The specialty of the consultant responsible for the person at the time of discharge.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Coded value
Description:
The coded value for discharge speciality
Valueset:
NHS data dictionary : - Activity treatment function code
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Free text
Description:
Free text field to be used if no code is available
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Discharging department
Description:
The department from which the person is discharged.
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Legal status on discharge
Description:
Whether the person was discharged as informal or formal/detained.
Valueset:
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Discharge destination
Description:
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Discharge destination
Description:
The destination of the person on discharge from hospital e.g. usual place of residence, NHS run care home.
Valueset:
NHS data dictionary - Discharge destination.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Discharge address
Description:
Address to which the person is discharged if not the usual place of residence.
Valueset:
NHS data dictionary :- Address
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Future appointments
Description:
Details of future appointments.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Future appointments record entry
Description:
This is the future appointments 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.
Valueset:
-
Cardinality: 0 ... *
MRO: R
Information type:
Name: Date of appointment
Description:
Date and time of future appointment.
Valueset:
Date and time
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Appointment status
Description:
The status of the appointment e.g. proposed, booked, confirmed, rejected.
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Reason for appointment
Description:
Reason this appointment is scheduled e.g. diagnosis, investigation, treatment or assessment
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Location of future appointment
Description:
The location of the appointment.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Coded value
Description:
The coded value for location
Valueset:
NHS data dictionary : - Organisation data service
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Free text
Description:
Free text field to be used if no code is available
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Specialty
Description:
The specialty e.g. physiotherapy, oncology, mental health etc.
Valueset:
NHS data dictionary :- Activity treatment function code
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Service
Description:
The service being provided.
Valueset:
SNOMED CT: - 1127531000000102 |Services simple reference set (foundation metadata concept)|
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Professional seeing the person
Description:
The name and role of the professional e.g. consultant, care worker, nurse consultant.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Name
Description:
The name of the professional seeing the person.
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Role
Description:
The role of the professional seeing the person.
Valueset:
FHIR value set : - sdsjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Investigation results
Description:
Investigation results
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Investigation results record entry
Description:
This is a investigation result record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
Valueset:
-
Cardinality: 0 ... *
MRO: R
Information type:
Name: Date
Description:
The date and time when the investigation was performed
Valueset:
Date and time
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Performing professional
Description:
The professional who performed the investigation.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Name
Description:
The name of the professional.
Valueset:
Free text.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Role
Description:
The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc
Valueset:
FHIR value set :- SDSjobroletype
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Grade
Description:
The grade of the professional.
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Speciality
Description:
The specialty of the professional e.g. physiotherapy, oncology, mental health etc
Valueset:
NHS data dictionary - Activity treatment function code
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Professional identifier
Description:
Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.
Valueset:
NHS data dictionary : - Professional registration identifier
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Organisation
Description:
The name of the organisation the professional works for.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Contact details
Description:
Contact details of the professional
Valueset:
NHS data dictionary - UK phone number
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Location
Description:
The location where the investigation took place.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Coded location
Description:
The coded value for location
Valueset:
NHS data dictionary : Organisation data service
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Free text
Description:
Free text field to be used if no code is available
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Investigation
Description:
The investigation performed.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Coded value
Description:
The coded value for investigation
Valueset:
SNOMED CT: - <71388002 |Procedure (procedure)|
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Free text
Description:
Free text field to be used if no code is available
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Investigation result
Description:
For each investigation, the result of the investigation. This can include a report which may have results for multiple tests.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Coded value
Description:
The coded value for investigation results
Valueset:
SNOMED CT:- <404684003 |Clinical finding (finding)| OR <243796009 |Situation with explicit context (situation)|
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Free text
Description:
Free text field to be used if no code is available
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Structured investigation result
Description:
A structured set of information for each investigation result.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Value
Description:
The value of the investigation result.
Valueset:
Numeric
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Units of measure
Description:
The units of the investigation result.
Valueset:
UCUM code
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Reference ranges
Description:
The reference range for the investigation result.
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Abnormal indicator
Description:
Indicator if the investigation is abnormal.
Valueset:
Abnormal or Normal
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Person completing record
Description:
Details of the person completing the record.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Name
Description:
The name of the person completing the record.
Valueset:
Free text.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Role
Description:
The organisational role of the person completing record.
Valueset:
FHIR value set :- SDSjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Grade
Description:
The grade of the person completing the record.
Valueset:
Free text.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Specialty
Description:
The main specialty of the person completing the record.
Valueset:
NHS data dictionary :- Activity treatment function code
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Organisation
Description:
The organisation the person completing the record works for.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Professional identifier
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.
Valueset:
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Date completed
Description:
The date and time the record was completed.
Valueset:
Date and time.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Contact details
Description:
Contact details of the person completing the record.
Valueset:
NHS data dictionary : - UK telephone number
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Investigations requested
Description:
Details of any investigations requested
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Investigations requested record entry
Description:
This is an investigation requested 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.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Date
Description:
The date the investigation was requested.
Valueset:
Date and time
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Location
Description:
The location where the investigation was requested.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Coded value
Description:
The coded value for location
Valueset:
NHS data dictionary: - Organisation data service
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Free text
Description:
Free text field to be used if no coded text available
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Performing professional
Description:
The professional who requested the investigation.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Name
Description:
The name of the professional.
Valueset:
Free text.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Role
Description:
The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc
Valueset:
FHIR value set :- SDSjobroletype
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Grade
Description:
The grade of the professional.
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Speciality
Description:
The specialty of the professional e.g. physiotherapy, oncology, mental health etc
Valueset:
NHS data dictionary - Activity treatment function code
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Professional identifier
Description:
Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.
Valueset:
NHS data dictionary : - Professional registration identifier
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Organisation
Description:
The name of the organisation the professional works for.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Contact details
Description:
Contact details of the professional
Valueset:
NHS data dictionary - UK phone number
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Investigation requested
Description:
The investigation that is requested. The investigation may refer to an individual test or a group of related tests or broader investigation required (so the investigator can determine the appropriate tests)
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Coded value
Description:
The coded value for Investigation requested
Valueset:
SNOMED CT: - <71388002 |Procedure (procedure)|
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Free text
Description:
Free text field to be used if no code is available
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Status of request
Description:
The status of the investigation request.
Valueset:
Code : - draft | active | suspended | completed | entered-in-error | cancelled
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Reason for request
Description:
An explanation or justification for why this investigation is being requested.
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Request priority
Description:
The urgency of the investigation requested.
Valueset:
Code : - routine | urgent | asap | stat
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Person completing record
Description:
Details of the person completing the record.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Name
Description:
The name of the person completing the record.
Valueset:
Free text.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Role
Description:
The organisational role of the person completing record.
Valueset:
FHIR value set :- SDSjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Grade
Description:
The grade of the person completing the record.
Valueset:
Free text.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Specialty
Description:
The main specialty of the person completing the record.
Valueset:
NHS data dictionary :- Activity treatment function code
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Organisation
Description:
The organisation the person completing the record works for.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Professional identifier
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.
Valueset:
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Date completed
Description:
The date and time the record was completed.
Valueset:
Date and time.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Contact details
Description:
Contact details of the person completing the record.
Valueset:
NHS data dictionary : - UK telephone number
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Examination findings
Description:
Examination findings
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Examination findings record entry
Description:
This is a examination findings record entry. There may be 0 to many record entry/entries under a section. Each record entry is made up of a number of elements or data items.
Valueset:
-
Cardinality: 0 ... *
MRO: R
Information type:
Name: Date
Description:
The date the examination was performed.
Valueset:
Date and time
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Performing professional
Description:
The professional who performed the examiniation.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Name
Description:
The name of the professional.
Valueset:
Free text.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Role
Description:
The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc
Valueset:
FHIR value set :- SDSjobroletype
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Grade
Description:
The grade of the professional.
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Speciality
Description:
The specialty of the professional e.g. physiotherapy, oncology, mental health etc
Valueset:
NHS data dictionary - Activity treatment function code
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Professional identifier
Description:
Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.
Valueset:
NHS data dictionary : - Professional registration identifier
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Organisation
Description:
The name of the organisation the professional works for.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Contact details
Description:
Contact details of the professional
Valueset:
NHS data dictionary - UK phone number
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Location
Description:
The location where the examination was performed.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Coded value
Description:
The coded value for location
Valueset:
NHS data dictionary : - Organisation data service
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Free text
Description:
Free text field to be used if no code is available
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Examination findings
Description:
The record of findings from the examinations performed.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Coded value
Description:
The coded value for examination findings
Valueset:
SNOMED CT : - ^1127581000000103 |Health issues simple reference set|
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Free text
Description:
Free text field to be used if no coded text available
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Observations
Description:
The record of essential physiological measurements, e.g., heart rate, blood pressure, temperature, pulse, height, weight, respiratory rate, oxygen saturation.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Observations record entry
Description:
This is an observations record entry. There may be 0 to many record entry/entries under a section. Each record entry is made up of a number of elements or data items.
Valueset:
-
Cardinality: 0 ... *
MRO: R
Information type:
Name: Coded value
Description:
The coded value for observations
Valueset:
SNOMED CT: - <363787002 | Observable entity (observable entity) |
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Value
Description:
The measured value of the observations
Valueset:
Enumerated value e.g. numeric, natural numbers, mild, moderate
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Units of measure
Description:
The units of measure for the observation.
Valueset:
UCUM code
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Site
Description:
The anatomical site at which the observation is taken
Valueset:
SNOMED CT: - 442083009 | Anatomical or acquired body structure (body structure) |
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Interpretation
Description:
The assessment made based on the result of the observation e.g high, low
Valueset:
FHIR value set: - Interpretation
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Free text
Description:
Free text field to be used if no code is available
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Person completing record
Description:
Details of the person completing the record.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Name
Description:
The name of the person completing the record.
Valueset:
Free text.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Role
Description:
The organisational role of the person completing record.
Valueset:
FHIR value set :- SDSjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Grade
Description:
The grade of the person completing the record.
Valueset:
Free text.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Specialty
Description:
The main specialty of the person completing the record.
Valueset:
NHS data dictionary :- Activity treatment function code
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Organisation
Description:
The organisation the person completing the record works for.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Professional identifier
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.
Valueset:
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Date completed
Description:
The date and time the record was completed.
Valueset:
Date and time.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Contact details
Description:
Contact details of the person completing the record.
Valueset:
NHS data dictionary : - UK telephone number
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Comments
Description:
Any further comments relating to the examination.
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Assessments
Description:
Details of the person's assessments
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Assessments record entry
Description:
This is the assessments record entry. There may be 0 to many record entry/entries under a section. Each record entry is made up of a number of elements or data items.
Valueset:
-
Cardinality: 0 ... *
MRO: R
Information type:
Name: Date
Description:
The date the assessment was done.
Valueset:
Date and time.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Location
Description:
The location where the assessment was done.
Valueset:
ODS code or free text.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Coded value
Description:
The coded value for location
Valueset:
NHS data dictionary: - Organisation data service
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Free text
Description:
Free text field to be used if no code is available
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Assessment type
Description:
The type of the assessment e.g. social care needs assessment.
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Assessment summary
Description:
The summary of the assessment
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Structured assessment
Description:
Details of the structured assessment.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Structured assessment name
Description:
Structured assessment name e.g. New York Heart Failure, Glasgow Coma scale, Activities of Daily Living (ADL) etc.
Valueset:
SNOMED CT
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Assessment score
Description:
The structured assessment score.
Valueset:
Free text.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Assessment value
Description:
The structured assessment value.
Valueset:
Numeric
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Global score
Description:
The total global score from the assessment.
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Subscale score
Description:
The subscale score of the structured assessment.
Valueset:
Free text.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Subscale value
Description:
The subscale value of the structured assessment.
Valueset:
Numeric
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Performing professional
Description:
The professional who did the assessment.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Name
Description:
The name of the professional.
Valueset:
Free text.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Role
Description:
The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc
Valueset:
FHIR value set :- SDSjobroletype
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Grade
Description:
The grade of the professional.
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Speciality
Description:
The specialty of the professional e.g. physiotherapy, oncology, mental health etc
Valueset:
NHS data dictionary - Activity treatment function code
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Professional identifier
Description:
Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.
Valueset:
NHS data dictionary : - Professional registration identifier
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Organisation
Description:
The name of the organisation the professional works for.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Contact details
Description:
Contact details of the professional
Valueset:
NHS data dictionary - UK phone number
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Person completing record
Description:
Details of the person completing the record.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Name
Description:
The name of the person completing the record.
Valueset:
Free text.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Role
Description:
The organisational role of the person completing record.
Valueset:
FHIR value set :- SDSjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Grade
Description:
The grade of the person completing the record.
Valueset:
Free text.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Specialty
Description:
The main specialty of the person completing the record.
Valueset:
NHS data dictionary :- Activity treatment function code
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Organisation
Description:
The organisation the person completing the record works for.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Professional identifier
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.
Valueset:
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Date completed
Description:
The date and time the record was completed.
Valueset:
Date and time.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Contact details
Description:
Contact details of the person completing the record.
Valueset:
NHS data dictionary : - UK telephone number
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Comment
Description:
Supporting text may be given regarding the assessment.
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Risks
Description:
Details of any risks related to the person.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Risks to self
Description:
Details of the persons risk to self
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Start date of risk
Description:
The start date of the risk.
Valueset:
Date and time
Cardinality: 0 ... 1
MRO: R
Information type:
Name: End date of risk
Description:
The date the risk ended.
Valueset:
Date and time
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Risk to self
Description:
Risks the person poses to themselves, e.g. suicide, overdose, self-harm, self-neglect.
Valueset:
SNOMED CT: - <281694009 |Finding of at risk (finding)|
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Location
Description:
The location where the risk was identified.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Coded value
Description:
The coded value for location
Valueset:
NHS data dictionary : - Organisation service code
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Free text
Description:
Free text field to be used if no code is available
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Performing professional
Description:
The professional who identified the risk.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Name
Description:
The name of the professional.
Valueset:
Free text.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Role
Description:
The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc
Valueset:
FHIR value set :- SDSjobroletype
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Grade
Description:
The grade of the professional.
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Speciality
Description:
The specialty of the professional e.g. physiotherapy, oncology, mental health etc
Valueset:
NHS data dictionary - Activity treatment function code
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Professional identifier
Description:
Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.
Valueset:
NHS data dictionary : - Professional registration identifier
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Organisation
Description:
The name of the organisation the professional works for.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Contact details
Description:
Contact details of the professional
Valueset:
NHS data dictionary - UK phone number
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Person completing record
Description:
Details of the person completing the record.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Name
Description:
The name of the person completing the record.
Valueset:
Free text.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Role
Description:
The organisational role of the person completing record.
Valueset:
FHIR value set :- SDSjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Grade
Description:
The grade of the person completing the record.
Valueset:
Free text.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Specialty
Description:
The main specialty of the person completing the record.
Valueset:
NHS data dictionary :- Activity treatment function code
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Organisation
Description:
The organisation the person completing the record works for.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Professional identifier
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.
Valueset:
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Date completed
Description:
The date and time the record was completed.
Valueset:
Date and time.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Contact details
Description:
Contact details of the person completing the record.
Valueset:
NHS data dictionary : - UK telephone number
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Risks to others
Description:
Details of the person's risk to others
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Start date of risk
Description:
The start date of the risk.
Valueset:
Date and time
Cardinality: 0 ... 1
MRO: R
Information type:
Name: End date of risk
Description:
The date the risk ended.
Valueset:
Date and time
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Risks to others
Description:
Risks to professionals or others.
Valueset:
SNOMED CT: - <<391155006 |At risk of harming others (finding)|
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Location
Description:
The location where the risk to others was identified.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Coded value
Description:
The coded value for location
Valueset:
NHS data dictionary : - Organisation data service
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Free text
Description:
Free text field to be used if no code is available
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Performing professional
Description:
The professional who identifies the risk to others.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Name
Description:
The name of the professional.
Valueset:
Free text.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Role
Description:
The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc
Valueset:
FHIR value set :- SDSjobroletype
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Grade
Description:
The grade of the professional.
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Speciality
Description:
The specialty of the professional e.g. physiotherapy, oncology, mental health etc
Valueset:
NHS data dictionary - Activity treatment function code
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Professional identifier
Description:
Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.
Valueset:
NHS data dictionary : - Professional registration identifier
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Organisation
Description:
The name of the organisation the professional works for.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Contact details
Description:
Contact details of the professional
Valueset:
NHS data dictionary - UK phone number
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Person completing record
Description:
Details of the person completing the record.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Name
Description:
The name of the person completing the record.
Valueset:
Free text.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Role
Description:
The organisational role of the person completing record.
Valueset:
FHIR value set :- SDSjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Grade
Description:
The grade of the person completing the record.
Valueset:
Free text.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Specialty
Description:
The main specialty of the person completing the record.
Valueset:
NHS data dictionary :- Activity treatment function code
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Organisation
Description:
The organisation the person completing the record works for.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Professional identifier
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.
Valueset:
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Date completed
Description:
The date and time the record was completed.
Valueset:
Date and time.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Contact details
Description:
Contact details of the person completing the record.
Valueset:
NHS data dictionary : - UK telephone number
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Risk from others
Description:
Risks to the person from an identified individual e.g. family member etc.
Valueset:
Free Text.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Start date of risk
Description:
The start date of the risk.
Valueset:
Date and time
Cardinality: 0 ... 1
MRO: R
Information type:
Name: End date of risk
Description:
The date the risk ended.
Valueset:
Date and time
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Risk from others
Description:
Risks to the person from an identified individual e.g. family member etc.
Valueset:
SNOMED CT: - <281694009 |Finding of at risk (finding)|
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Location
Description:
The location where the risk from others was identified.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Coded value
Description:
The coded value for location
Valueset:
NHS data dictionary : - Organisation data service
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Free text
Description:
Free text field to be used if no code is available
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Performing professional
Description:
The professional who identified the risk from others.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Name
Description:
The name of the professional.
Valueset:
Free text.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Role
Description:
The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc
Valueset:
FHIR value set :- SDSjobroletype
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Grade
Description:
The grade of the professional.
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Speciality
Description:
The specialty of the professional e.g. physiotherapy, oncology, mental health etc
Valueset:
NHS data dictionary - Activity treatment function code
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Professional identifier
Description:
Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.
Valueset:
NHS data dictionary : - Professional registration identifier
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Organisation
Description:
The name of the organisation the professional works for.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Contact details
Description:
Contact details of the professional
Valueset:
NHS data dictionary - UK phone number
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Person completing record
Description:
Details of the person completing the record.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Name
Description:
The name of the person completing the record.
Valueset:
Free text.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Role
Description:
The organisational role of the person completing record.
Valueset:
FHIR value set :- SDSjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Grade
Description:
The grade of the person completing the record.
Valueset:
Free text.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Specialty
Description:
The main specialty of the person completing the record.
Valueset:
NHS data dictionary :- Activity treatment function code
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Organisation
Description:
The organisation the person completing the record works for.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Professional identifier
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.
Valueset:
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Date completed
Description:
The date and time the record was completed.
Valueset:
Date and time.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Contact details
Description:
Contact details of the person completing the record.
Valueset:
NHS data dictionary : - UK telephone number
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Risk of accidents
Description:
Details of the risks the person poses to themselves from accidents.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Start date of risk
Description:
The start date of the risk.
Valueset:
Date and time
Cardinality: 0 ... 1
MRO: R
Information type:
Name: End date of risk
Description:
The date the risk ended.
Valueset:
Date and time
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Risk of accidents
Description:
Risks the person poses to themselves from accidents.
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Location
Description:
The location where the risk of accidents was identified.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Coded value
Description:
The coded value for location
Valueset:
NHS data dictionary : - Organisation data service
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Free text
Description:
Free text field to be used if no coded text available
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Performing professional
Description:
The professional who identified the risk of accidents.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Name
Description:
The name of the professional.
Valueset:
Free text.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Role
Description:
The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc
Valueset:
FHIR value set :- SDSjobroletype
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Grade
Description:
The grade of the professional.
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Speciality
Description:
The specialty of the professional e.g. physiotherapy, oncology, mental health etc
Valueset:
NHS data dictionary - Activity treatment function code
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Professional identifier
Description:
Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.
Valueset:
NHS data dictionary : - Professional registration identifier
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Organisation
Description:
The name of the organisation the professional works for.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Contact details
Description:
Contact details of the professional
Valueset:
NHS data dictionary - UK phone number
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Person completing record
Description:
Details of the person completing the record.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Name
Description:
The name of the person completing the record.
Valueset:
Free text.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Role
Description:
The organisational role of the person completing record.
Valueset:
FHIR value set :- SDSjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Grade
Description:
The grade of the person completing the record.
Valueset:
Free text.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Specialty
Description:
The main specialty of the person completing the record.
Valueset:
NHS data dictionary :- Activity treatment function code
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Organisation
Description:
The organisation the person completing the record works for.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Professional identifier
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.
Valueset:
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Date completed
Description:
The date and time the record was completed.
Valueset:
Date and time.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Contact details
Description:
Contact details of the person completing the record.
Valueset:
NHS data dictionary : - UK telephone number
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Other risks
Description:
Details of other risks, factors or behaviours relating to the person.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Start date of risk
Description:
The start date of the risk.
Valueset:
Date and time
Cardinality: 0 ... 1
MRO: R
Information type:
Name: End date of risk
Description:
The date the risk ended.
Valueset:
Date and time
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Other risks
Description:
Other risks, factors or behaviours relating to the person.
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Location
Description:
The location where the other risks were identified.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Coded value
Description:
The coded value for location
Valueset:
NHS data dictionary : - Organisation data service
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Free text
Description:
Free text field to be used if no code is available
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Performing professional
Description:
The professional who identified the other risks.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Name
Description:
The name of the professional.
Valueset:
Free text.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Role
Description:
The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc
Valueset:
FHIR value set :- SDSjobroletype
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Grade
Description:
The grade of the professional.
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Speciality
Description:
The specialty of the professional e.g. physiotherapy, oncology, mental health etc
Valueset:
NHS data dictionary - Activity treatment function code
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Professional identifier
Description:
Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.
Valueset:
NHS data dictionary : - Professional registration identifier
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Organisation
Description:
The name of the organisation the professional works for.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Contact details
Description:
Contact details of the professional
Valueset:
NHS data dictionary - UK phone number
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Person completing record
Description:
Details of the person completing the record.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Name
Description:
The name of the person completing the record.
Valueset:
Free text.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Role
Description:
The organisational role of the person completing record.
Valueset:
FHIR value set :- SDSjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Grade
Description:
The grade of the person completing the record.
Valueset:
Free text.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Specialty
Description:
The main specialty of the person completing the record.
Valueset:
NHS data dictionary :- Activity treatment function code
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Organisation
Description:
The organisation the person completing the record works for.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Professional identifier
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.
Valueset:
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Date completed
Description:
The date and time the record was completed.
Valueset:
Date and time.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Contact details
Description:
Contact details of the person completing the record.
Valueset:
NHS data dictionary : - UK telephone number
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Allergies and adverse reactions
Description:
Allergies and adverse reactions
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Allergies and adverse reactions record entry
Description:
This is a allergies and adverse reactions record entry. There may be 1 to many record entries under a section.

Each record entry is made up of a number of elements or data items.
Valueset:
-
Cardinality: 0 ... *
MRO: R
Information type:
Name: Type of reaction
Description:
The type of reaction experienced by the person (allergic, adverse, intolerance)
Valueset:
FHIR value set :- Allergy, Intolerance
Cardinality: 0 ... 1
MRO: M
Information type:
Name: Causative agent
Description:
The agent such as food, drug or substances that has caused or may cause an allergy, intolerance or adverse reaction in this person Or “No known drug allergies or adverse reactions” Or “Information not available”
Valueset:
-
Cardinality: 1 ... 1
MRO: R
Information type:
Name: Coded value
Description:
The coded value for causative agent
Valueset:
SNOMED CT : - <105590001 |Substance OR <373873005 |Pharmaceutical / biologic product| OR <<716186003 |No known allergy| OR 196461000000101 |Transfer-degraded drug allergy| OR 196471000000108 |Transfer-degraded non-drug allergy)
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Free text
Description:
Free text field to be used if no code is available
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Reaction details cluster
Description:
Details of the reaction.
Valueset:
-
Cardinality: 0 ... *
MRO: R
Information type:
Name: Date
Description:
The date that the reaction was identified.
Valueset:
Date and time
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Location
Description:
Details of where the allergy was identified. Linked to the date of the diagnosis by the professional.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Coded value
Description:
The coded value for location.
Valueset:
NHS data dictionary : - Organisation data service
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Free text
Description:
Free text field to be used if no code is available
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Substance
Description:
The substance, or a class of substances, that is considered to be responsible for the adverse reaction.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Coded value
Description:
The coded value for substance
Valueset:
SNOMED CT : - <105590001 | Substance (substance) | or <373873005 | Pharmaceutical / biologic product (product) |
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Free text
Description:
Free text field to be used if no code is available
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Description of reaction
Description:
A description of the manifestation of the allergic or adverse reaction experienced by the person. For example, skin rash.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Coded value
Description:
The coded value for description of reaction.
Valueset:
SNOMED CT: - ^1127581000000103 |Health issues simple reference set|
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Free text
Description:
Free text field to be used if no code is available
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Onset date
Description:
Date and time when manifestations showed e.g could be at home a few days earlier than the contact
Valueset:
Date and time
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Severity
Description:
A description of the severity of the reaction.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Coded value
Description:
The coded value for severity
Valueset:
FHIR value set : - Severity
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Free text
Description:
Free text field to be used if no code is available
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Certainty
Description:
A description of the certainty that the stated causative agent caused the allergic or adverse reaction.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Coded value
Description:
The coded value for certainty.
Valueset:
FHIR value set : - Certainty
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Free text
Description:
Free text field to be used if no code is available
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Route of exposure
Description:
The route the person was exposed to the substance
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Coded value
Description:
The coded value for route of exposure
Valueset:
SNOMED CT: - ^999000051000001100 |ePrescribing route of administration simple reference set|
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Free text
Description:
Free text field to be used if no coded text available
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Comment
Description:
Any additional comment or clarification about the adverse reaction.
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Evidence
Description:
Results of investigations that confirmed the certainty of the diagnosis. Examples might include results of skin prick allergy tests
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Date first experienced
Description:
When the reaction was first experienced i.e this may not be the first this has happened. May be a date or partial date (e.g. year) or text (e.g. during childhood)
Valueset:
Date and time
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Allergy end date
Description:
The date the allergy was diagnosed as ended
Valueset:
Date and time 
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Comment
Description:
Any further comments on the person's allergies or adverse reactions.
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Performing professional
Description:
The professional who identified the reaction.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Name
Description:
The name of the professional.
Valueset:
Free text.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Role
Description:
The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc
Valueset:
FHIR value set :- SDSjobroletype
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Grade
Description:
The grade of the professional.
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Speciality
Description:
The specialty of the professional e.g. physiotherapy, oncology, mental health etc
Valueset:
NHS data dictionary - Activity treatment function code
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Professional identifier
Description:
Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.
Valueset:
NHS data dictionary : - Professional registration identifier
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Organisation
Description:
The name of the organisation the professional works for.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Contact details
Description:
Contact details of the professional
Valueset:
NHS data dictionary - UK phone number
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Person completing record
Description:
Details of the person completing the record.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Name
Description:
The name of the person completing the record.
Valueset:
Free text.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Role
Description:
The organisational role of the person completing record.
Valueset:
FHIR value set :- SDSjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Grade
Description:
The grade of the person completing the record.
Valueset:
Free text.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Specialty
Description:
The main specialty of the person completing the record.
Valueset:
NHS data dictionary :- Activity treatment function code
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Organisation
Description:
The organisation the person completing the record works for.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Professional identifier
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.
Valueset:
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Date completed
Description:
The date and time the record was completed.
Valueset:
Date and time.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Contact details
Description:
Contact details of the person completing the record.
Valueset:
NHS data dictionary : - UK telephone number
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Medications and medical devices
Description:
Medications and medical devices
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Medication administration record entry
Description:
Each entry holds details of medications administered
Valueset:
-
Cardinality: 0 ... *
MRO: R
Information type:
Name: Medication name
Description:
May be generic name or brand name.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Coded value
Description:
The coded value for medication name
Valueset:
SNOMED CT: - ^999000581000001102 |National Health Service dictionary of medicines and devices virtual therapeutic moiety simple reference set (foundation metadata concept)| OR ^999000561000001109 |National Health Service dictionary of medicines and devices virtual medicinal product simple reference set (foundation metadata concept)| OR ^999000571000001104 |National Health Service dictionary of medicines and devices virtual medicinal product pack simple reference set (foundation metadata concept)| OR ^999000541000001108 |National Health Service dictionary of medicines and devices actual medicinal product simple reference set (foundation metadata concept)| OR ^999000551000001106 |National Health Service dictionary of medicines and devices actual medicinal product pack simple reference set (foundation metadata concept)|
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Free text
Description:
Free text field to be used if no code is available
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Route
Description:
The route by which the medication is administered e.g. oral, IM, IV
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Coded value
Description:
The coded value for route
Valueset:
SNOMED CT: - 999000051000001100 |ePrescribing route of administration simple reference set (foundation metadata concept)|
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Free text
Description:
Free text field to be used if no code is available
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Dose administered
Description:
The quantity and units of medication administered
Valueset:
Free text. The quantity and units administered
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Administration date and time
Description:
The date and time when the medication was administered.
Valueset:
Date and time
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Medication item entry
Description:
All medications and devices that can be prescribed to be entered via this Medication item entry. Handles details of continuation / addition / amendment of admission medications.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Medication item cluster
Description:
Medication item cluster
Valueset:
-
Cardinality: 0 ... *
MRO: R
Information type:
Name: Date
Description:
The date on which the medication or medical device was prescribed.
Valueset:
Date and time
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Location
Description:
The location where the medication or the medical device was prescribed.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Coded value
Description:
The coded value for location
Valueset:
NHS data dictionary : - Organisation data service
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Free text
Description:
Free text field to be used if no code is available
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Performing professional
Description:
The professional who prescribed the medication or medical device.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Name
Description:
The name of the professional.
Valueset:
Free text.
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Role
Description:
The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc
Valueset:
FHIR value set :- SDSjobroletype
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Grade
Description:
The grade of the professional.
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Speciality
Description:
The specialty of the professional e.g. physiotherapy, oncology, mental health etc
Valueset:
NHS data dictionary - Activity treatment function code
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Professional identifier
Description:
Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.
Valueset:
NHS data dictionary : - Professional registration identifier
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Organisation
Description:
The name of the organisation the professional works for.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Contact details
Description:
Contact details of the professional
Valueset:
NHS data dictionary - UK phone number
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Medication name
Description:
May be generic name or brand name.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Coded value
Description:
The coded value for medication name
Valueset:
SNOMED CT: - ^999000581000001102 |National Health Service dictionary of medicines and devices virtual therapeutic moiety simple reference set (foundation metadata concept)| OR ^999000561000001109 |National Health Service dictionary of medicines and devices virtual medicinal product simple reference set (foundation metadata concept)| OR ^999000571000001104 |National Health Service dictionary of medicines and devices virtual medicinal product pack simple reference set (foundation metadata concept)| OR ^999000541000001108 |National Health Service dictionary of medicines and devices actual medicinal product simple reference set (foundation metadata concept)| OR ^999000551000001106 |National Health Service dictionary of medicines and devices actual medicinal product pack simple reference set (foundation metadata concept)|
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Free text
Description:
Free text field to be used if no code is available
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Form
Description:
The form of the medication e.g. capsule, drops, tablet, lotion etc.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Coded value
Description:
The coded value for form.
Valueset:
SNOMED CT: - 421967003 | Drug dose form (qualifier value) |
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Free text
Description:
Free text field to be used if no code is available
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Route
Description:
The route by which the medication is administered e.g. oral, IM, IV
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Coded value
Description:
The coded value for route
Valueset:
SNOMED CT: - 999000051000001100 |ePrescribing route of administration simple reference set (foundation metadata concept)|
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Free text
Description:
Free text field to be used if no code is available
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Site
Description:
The anatomical site at which the medication is to be administered.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Coded value
Description:
The coded value for site
Valueset:

SNOMED CT: - <442083009 | Anatomical or acquired body structure (body structure) |
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Free text
Description:
Amount of vaccine administered.
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Method
Description:
The technique or method by which the medication is to be administered.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Dose directions description
Description:
Describes the entire medication dosage and administration directions including dose quantity and medication frequency and optionally duration e.g. “1 tablet at night" or “2mg at 10pm”.
Valueset:
Free text
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Structured dose direction cluster
Description:
A structural representation of the elements carried by the dose syntax in 'parsable dose strength / timing' i.e. dose strength, dose timing, dose duration and maximum dose.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Structured dose amount
Description:
A structural representation of dose amount, e.g. 20mg or 2 tablets. This element will generally only be used when persisting data within systems with 'parsable dose directions' being used to exchange the same information between systems.
Valueset:
As per FHIR Dose Syntax Implementation Guidance (NHS Digital):https://developer.nhs.uk/apis/dose-syntax-implementation-1-3-1-alpha/
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Structured dose timing
Description:
A slot containing a structural, computable representation of dose timing and maximum dose. This element will generally only be used when persisting data within systems with 'parsable dose directions' being used to exchange the same information between systems.
Valueset:
As per FHIR Dose Syntax Implementation Guidance (NHS Digital):https://developer.nhs.uk/apis/dose-syntax-implementation-1-3-1-alpha/
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Dose direction duration
Description:
Recommendation of the time period for which the medication should be continued, including direction not to discontinue.
Valueset:
As per FHIR Dose Syntax Implementation Guidance (NHS Digital):https://developer.nhs.uk/apis/dose-syntax-implementation-1-3-1-alpha/
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Additional instructions
Description:
Allows for: requirements for adherence support, e.g. compliance aids, prompts and packaging requirements, additional information about specific medicines e.g. where specific brand required, person requirements, e.g. unable to swallow tablets.
Valueset:
FHIR value set : - Additional instruction
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Course details cluster
Description:
Details of the overall course of medication.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Name: Course status
Description:
The status of this prescription.
Valueset:
FHIR value set : - Medication status
    Cardinality: 0 ... 1
    MRO: R
    Information type:
    Name: Indication
    Description:
    Reason for medication being prescribed, where known.
    Valueset:
    Free text
    Cardinality: 0 ... 1
    MRO: R
    Information type:
    Name: Start date/time
    Description:
    The date and/or time that the medication course should begin.
    Valueset:
    Date and time
    Cardinality: 0 ... 1
    MRO: R
    Information type:
    Name: End date/time
    Description:
    The date and/or time that the medication course should finish.
    Valueset:
    Date and time
    Cardinality: 0 ... 1
    MRO: R
    Information type:
    Name: Link to indication record
    Description:
    A link to the record which contains the indication for this medication order.
    Valueset:
    Free text with URL
    Cardinality: 0 ... 1
    MRO: R
    Information type:
    Name: Comment/recommendation
    Description:
    Suggestions about duration and/or review, ongoing monitoring requirements, advice on starting, discontinuing or changing medication. Additional comment or recommendation about the medication course e.g. 'Patient named supply', 'unlicensed medication', 'Foreign brand' or monitoring recommendations
    Valueset:
    Free text
    Cardinality: 0 ... 1
    MRO: R
    Information type:
    Name: Medication change summary cluster
    Description:
    Records the changes made to medication.
    Valueset:
    -
    Cardinality: 0 ... 1
    MRO: R
    Information type:
    Name: Status
    Description:
    The nature of any change made to the medication.
    Valueset:
    FHIR value set : Medication status
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Indication
      Description:
      Reason for change in medication, e.g. sub-therapeutic dose, person intolerant.
      Valueset:
      Free text
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Date of change
      Description:
      The date of the change - addition, or amendment
      Valueset:
      Date and time
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Description of amendment
      Description:
      Where a change is made to the medication i.e. one drug stopped and another started or eg dose, frequency or route is changed.
      Valueset:
      Free text
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Total dose daily quantity
      Description:
      The total daily dose of this medication. This is helpful for estimating optimal adherence to dosing guidance. It may be computed from product/dose strength and frequency or entered manually.
      Valueset:
      Free text
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Person completing record
      Description:
      Details of the person completing the record.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Name
      Description:
      The name of the person completing the record.
      Valueset:
      Free text.
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Role
      Description:
      The organisational role of the person completing record.
      Valueset:
      FHIR value set :- SDSjobrole
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Grade
      Description:
      The grade of the person completing the record.
      Valueset:
      Free text.
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Specialty
      Description:
      The main specialty of the person completing the record.
      Valueset:
      NHS data dictionary :- Activity treatment function code
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Organisation
      Description:
      The organisation the person completing the record works for.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Professional identifier
      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.
      Valueset:
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Date completed
      Description:
      The date and time the record was completed.
      Valueset:
      Date and time.
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Contact details
      Description:
      Contact details of the person completing the record.
      Valueset:
      NHS data dictionary : - UK telephone number
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Medical devices entry
      Description:
      Medical devices
      Valueset:
      -
      Cardinality: 0 ... *
      MRO: R
      Information type:
      Name: Medical device
      Description:
      Any medical device that isn't prescribed.
      Valueset:
      Free text
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Comments
      Description:
      Any information regarding the medical device.
      Valueset:
      Free text
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Medication discontinued entry
      Description:
      Medication discontinued entry
      Valueset:
      -
      Cardinality: 0 ... *
      MRO: R
      Information type:
      Name: Name of discontinued medication
      Description:
      The name of the medication or medical device being discontinued
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Coded value
      Description:
      The coded value for medication name
      Valueset:
      SNOMED CT: - ^999000581000001102 |National Health Service dictionary of medicines and devices virtual therapeutic moiety simple reference set (foundation metadata concept)| OR ^999000561000001109 |National Health Service dictionary of medicines and devices virtual medicinal product simple reference set (foundation metadata concept)| OR ^999000571000001104 |National Health Service dictionary of medicines and devices virtual medicinal product pack simple reference set (foundation metadata concept)| OR ^999000541000001108 |National Health Service dictionary of medicines and devices actual medicinal product simple reference set (foundation metadata concept)| OR ^999000551000001106 |National Health Service dictionary of medicines and devices actual medicinal product pack simple reference set (foundation metadata concept)|
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Free text
      Description:
      Amount of vaccine administered.
      Valueset:
      Free text
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Status
      Description:
      The status of any change made to the medication. MUST CONTAIN STOPPED.
      Valueset:
      FHIR value set: - Medication status
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Indication
      Description:
      The clinical indication for any changes in medication status
      Valueset:
      Free text
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Date of change
      Description:
      The date of the discontinuation
      Valueset:
      Date and time
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Comment
      Description:
      Any additional comment about the discontinuation or amendment.
      Valueset:
      Free text
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Care and support plan
      Description:
      This records the decisions reached during conversation between the individual and health and care professional about future plans and also records progress.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Strengths
      Description:
      Any strengths and assets the person has relating to their goals and hopes about their health and well-being.
      Valueset:
      Free text
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Needs, concerns or problems
      Description:
      Needs, concerns or problems the person has that relating to their health and well-being. May be linked to the problem list from the person’s record to avoid duplication. May include biological, psychological and social needs, concerns or problems. May include (eg) financial concerns over debt.
      Valueset:
      Free text
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Goals and hopes
      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.
      Valueset:
      Free text
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Actions and activities
      Description:
      Actions or activities the person or others plan to take to achieve the person's goals and the resources required to do this.

      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Stage goal
      Description:
      A specific sub-goal that is related to the overall goal as agreed by the person in collaboration with a professional.
      Valueset:
      Free text
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: What
      Description:
      What the action is and how it is to be carried out?
      Valueset:
      Free text.
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Who
      Description:
      Name and role (e.g. person, carer, GP, OT, etc.) of the person, or a team, carrying out the proposed action, and, if relevant where action should take place.
      Valueset:
      Free text.
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: When
      Description:
      Planned date, time, or interval, as relevant
      Valueset:
      Date and time
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Suggested strategies
      Description:
      Suggested strategies for potential problems.
      Valueset:
      Free text.
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Status
      Description:
      The status of the action or activity e.g. started, not started, completed, not applicable.
      Valueset:
      Free text.
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Confidence
      Description:
      How confident the person feels to carry it out
      Valueset:
      Free text.
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Outcome
      Description:
      The outcome of the stage goal
      Valueset:
      Free text.
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Date last updated
      Description:
      Date when action/activity record was last updated
      Valueset:
      Date and time
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Review date
      Description:
      When the stage goal and action need to be reviewed.
      Valueset:
      Date and time.
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Outcomes
      Description:
      Outcomes of each of the person’s goals, aims and targets. Includes comments recorded by the person, date and status.
      Valueset:
      Free text
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Agreed with person or legitimate representative
      Description:
      Indicates whether the plan was discussed and agreed with the person or legitimate representative. A record of the agreement of the decisions made.
      Valueset:
      Free text
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Care funding source
      Description:
      A reference to the funding source and any conditions or limitations associated.
      Valueset:
      Free text
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Date this plan was last updated
      Description:
      This is a record of the date that this care and support plan was last updated.
      Valueset:
      Date and time
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Other care planning documents
      Description:
      Reference other care planning documents, including the type, location and date.

      This may include condition-specific plans, advance care plans, end of life care plan, etc.
      Valueset:
      Free text.
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Planned review date/interval
      Description:
      This is the date/interval when this information will next be reviewed.
      Valueset:
      Date and time
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Responsibility for review
      Description:
      This is a record of who has responsibility for arranging review of this information.

      Should include their name, role and contact details.
      Valueset:
      Free text.
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Location
      Description:
      The location where the care and support plan was prepared.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Coded value
      Description:
      The coded value for location
      Valueset:
      NHS data dictionary: - Organisation data service
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Free text
      Description:
      Free text field to be used if no coded text available
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Performing professional
      Description:
      The professional who prepared the care and support plan.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Name
      Description:
      The name of the professional.
      Valueset:
      Free text.
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Role
      Description:
      The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc
      Valueset:
      FHIR value set :- SDSjobroletype
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Grade
      Description:
      The grade of the professional.
      Valueset:
      Free text
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Speciality
      Description:
      The specialty of the professional e.g. physiotherapy, oncology, mental health etc
      Valueset:
      NHS data dictionary - Activity treatment function code
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Professional identifier
      Description:
      Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.
      Valueset:
      NHS data dictionary : - Professional registration identifier
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Organisation
      Description:
      The name of the organisation the professional works for.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Contact details
      Description:
      Contact details of the professional
      Valueset:
      NHS data dictionary - UK phone number
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Person completing record
      Description:
      Details of the person completing the record.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Name
      Description:
      The name of the person completing the record.
      Valueset:
      Free text.
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Role
      Description:
      The organisational role of the person completing record.
      Valueset:
      FHIR value set :- SDSjobrole
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Grade
      Description:
      The grade of the person completing the record.
      Valueset:
      Free text.
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Specialty
      Description:
      The main specialty of the person completing the record.
      Valueset:
      NHS data dictionary :- Activity treatment function code
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Organisation
      Description:
      The organisation the person completing the record works for.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Professional identifier
      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.
      Valueset:
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Date completed
      Description:
      The date and time the record was completed.
      Valueset:
      Date and time.
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Contact details
      Description:
      Contact details of the person completing the record.
      Valueset:
      NHS data dictionary : - UK telephone number
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Contingency plans
      Description:
      Contingency plans.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Agreed with person or legitimate representative
      Description:
      Indicates whether the plan was discussed and agreed with the person or legitimate representative.
      Valueset:
      Free text
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Anticipatory medicines/equipment
      Description:
      Medicines or equipment available that may be required in specific situations and their location. A statement regarding the availability or location of the anticipatory medicines/equipment.
      Valueset:
      Free text
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Advance statement
      Description:
      Written requests and preferences made by a person with capacity conveying their wishes, beliefs and values for their future care should they lose capacity.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Date
      Description:
      The date when the advanced statements was made.
      Valueset:
      Date and time
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Location
      Description:
      The location where the advanced statement was made.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Coded value
      Description:
      The coded value for location
      Valueset:
      NHS data dictionary: - Organisation data service
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Free text
      Description:
      Free text field to be used if no code is available
      Valueset:
      Free text
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Advance statement
      Description:
      Does the person have an advance statement.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Coded value
      Description:
      The coded value for advance statement
      Valueset:
      SNOMED CT: - 816281000000101 | Has advance statement (Mental Capacity Act 2005) (finding) |
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Free text
      Description:
      Free text field to be used if no code is available
      Valueset:
      Free text
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Location of document
      Description:
      The location of where the advanced statement is held.
      Valueset:
      Free text or URL
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Performing professional
      Description:
      The professional who made the advance statement.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Name
      Description:
      The name of the professional.
      Valueset:
      Free text.
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Role
      Description:
      The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc
      Valueset:
      FHIR value set :- SDSjobroletype
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Grade
      Description:
      The grade of the professional.
      Valueset:
      Free text
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Speciality
      Description:
      The specialty of the professional e.g. physiotherapy, oncology, mental health etc
      Valueset:
      NHS data dictionary - Activity treatment function code
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Professional identifier
      Description:
      Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.
      Valueset:
      NHS data dictionary : - Professional registration identifier
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Organisation
      Description:
      The name of the organisation the professional works for.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Contact details
      Description:
      Contact details of the professional
      Valueset:
      NHS data dictionary - UK phone number
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Person completing record
      Description:
      Details of the person completing the record.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Name
      Description:
      The name of the person completing the record.
      Valueset:
      Free text.
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Role
      Description:
      The organisational role of the person completing record.
      Valueset:
      FHIR value set :- SDSjobrole
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Grade
      Description:
      The grade of the person completing the record.
      Valueset:
      Free text.
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Specialty
      Description:
      The main specialty of the person completing the record.
      Valueset:
      NHS data dictionary :- Activity treatment function code
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Organisation
      Description:
      The organisation the person completing the record works for.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Professional identifier
      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.
      Valueset:
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Date completed
      Description:
      The date and time the record was completed.
      Valueset:
      Date and time.
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Contact details
      Description:
      Contact details of the person completing the record.
      Valueset:
      NHS data dictionary : - UK telephone number
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Contingency plan name
      Description:
      Name of the contingency plan – what condition or circumstances it is addressing.
      Valueset:
      Free text
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Date this plan was last updated
      Description:
      The date that this contingency plan was last updated.
      Valueset:
      Date and time
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Planned review date/interval
      Description:
      This is the date/interval when this contingency plan will next be reviewed.
      Valueset:
      Date and time
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Responsibility for review
      Description:
      This is who has responsibility for arranging review of this information.

      Should include their name, role and contact details.
      Valueset:
      Free text.
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Trigger factors
      Description:
      Signs to watch out for that may indicate a significant change in health or other circumstances. A statement of trigger factors.
      Valueset:
      Free text
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Coping strategies
      Description:
      Details of coping strategies used
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Coping strategy
      Description:
      The coping strategies are defined as thoughts and behaviours that people use to manage the internal and external demands of situations that are appraised as stressful. This should also include a record of any tools used to carry out the coping strategy.
      Valueset:
      Free text
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Start date
      Description:
      The date when the coping strategy started
      Valueset:
      Date and time
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: End date
      Description:
      The date when the coping strategy ended
      Valueset:
      Date and time
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Relapse indicators / early warning signs
      Description:
      Details of the relapse indicators for the person. These may also be called 'early warning signs'
      Valueset:
      Free text
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: What should happen
      Description:
      Guidance on specific actions or interventions that may be required or should be avoided in specific situations. This may include circumstances where action needs to be taken if a carer is unable to care for the person. A statement of suggested actions. Usually expressed as: in the event of X do Y.
      Valueset:
      Free text
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Who should be contacted
      Description:
      Who should be contacted in the event of significant problems or deterioration in health or wellbeing. E.g. name, role and contact details.
      Valueset:
      Free text
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Location
      Description:
      The location where the contingency plan was prepared.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Coded value
      Description:
      The coded value for location
      Valueset:
      NHS data dictionary : - Organisation data service
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Free text
      Description:
      Free text field to be used if no code is available
      Valueset:
      Free text
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Performing professional
      Description:
      The professional who prepared the contingency plans.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Name
      Description:
      The name of the professional.
      Valueset:
      Free text.
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Role
      Description:
      The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc
      Valueset:
      FHIR value set :- SDSjobroletype
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Grade
      Description:
      The grade of the professional.
      Valueset:
      Free text
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Speciality
      Description:
      The specialty of the professional e.g. physiotherapy, oncology, mental health etc
      Valueset:
      NHS data dictionary - Activity treatment function code
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Professional identifier
      Description:
      Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.
      Valueset:
      NHS data dictionary : - Professional registration identifier
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Organisation
      Description:
      The name of the organisation the professional works for.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Contact details
      Description:
      Contact details of the professional
      Valueset:
      NHS data dictionary - UK phone number
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Person completing record
      Description:
      Details of the person completing the record.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Name
      Description:
      The name of the person completing the record.
      Valueset:
      Free text.
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Role
      Description:
      The organisational role of the person completing record.
      Valueset:
      FHIR value set :- SDSjobrole
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Grade
      Description:
      The grade of the person completing the record.
      Valueset:
      Free text.
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Specialty
      Description:
      The main specialty of the person completing the record.
      Valueset:
      NHS data dictionary :- Activity treatment function code
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Organisation
      Description:
      The organisation the person completing the record works for.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Professional identifier
      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.
      Valueset:
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Date completed
      Description:
      The date and time the record was completed.
      Valueset:
      Date and time.
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Contact details
      Description:
      Contact details of the person completing the record.
      Valueset:
      NHS data dictionary : - UK telephone number
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Additional support plans
      Description:
      Additional support plans
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Additional support plan name
      Description:
      The name of the particular additional supporting plan, e.g. dieticians plan, wound management plan, discharge management plan and behaviour support plan.
      Valueset:
      Free text
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Additional support plan content
      Description:
      This is the content of any additional care and support plan which the person and/or care professional consider should be shared with others providing care and support. May be structured in different ways, e.g. tables, diagrams, images. This is the content of any additional care and support plan which the individual and/or care professional consider should be shared with others providing care and support. It should be structured as recommended for the care and support plan and if contains additional detail, it may be referenced here.
      Valueset:
      Free text
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Planned review date/interval
      Description:
      This is the date/interval when this information will next be reviewed.
      Valueset:
      Date and time
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Responsibility for review
      Description:
      This is a record of who has responsibility for arranging review of this information. Should include their name, role and contact details.
      Valueset:
      Free text.
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Date this plan was last updated
      Description:
      This is a record of the date that this information was last updated.
      Valueset:
      Date and time
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Location
      Description:
      The location where the additional support plan was prepared.
      Valueset:
      ODS code or free text
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Coded value
      Description:
      The coded value for location
      Valueset:
      NHS data dictionary:- Organisation data service
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Free text
      Description:
      Free text field to be used if no code is available
      Valueset:
      Free text
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Performing professional
      Description:
      The professional who prepared the additional support plan.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Name
      Description:
      The name of the professional.
      Valueset:
      Free text.
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Role
      Description:
      The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc
      Valueset:
      FHIR value set :- SDSjobroletype
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Grade
      Description:
      The grade of the professional.
      Valueset:
      Free text
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Speciality
      Description:
      The specialty of the professional e.g. physiotherapy, oncology, mental health etc
      Valueset:
      NHS data dictionary - Activity treatment function code
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Professional identifier
      Description:
      Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.
      Valueset:
      NHS data dictionary : - Professional registration identifier
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Organisation
      Description:
      The name of the organisation the professional works for.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Contact details
      Description:
      Contact details of the professional
      Valueset:
      NHS data dictionary - UK phone number
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Person completing record
      Description:
      Details of the person completing the record.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Name
      Description:
      The name of the person completing the record.
      Valueset:
      Free text.
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Role
      Description:
      The organisational role of the person completing record.
      Valueset:
      FHIR value set :- SDSjobrole
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Grade
      Description:
      The grade of the person completing the record.
      Valueset:
      Free text.
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Specialty
      Description:
      The main specialty of the person completing the record.
      Valueset:
      NHS data dictionary :- Activity treatment function code
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Organisation
      Description:
      The organisation the person completing the record works for.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Professional identifier
      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.
      Valueset:
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Date completed
      Description:
      The date and time the record was completed.
      Valueset:
      Date and time.
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Contact details
      Description:
      Contact details of the person completing the record.
      Valueset:
      NHS data dictionary : - UK telephone number
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: End of life care
      Description:
      Information relating to end of life care.

      N.B. This is not an end of life care plan but contains information that would be found in an end of life care plan.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Cardio-pulmonary resuscitation (CPR) decision
      Description:
      Whether a decision has been made, the decision, who made the decision, the date of decision, date for review and location of documentation. Where the person or their family member/carer have not been informed of the clinical decision please state the reason why.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Date
      Description:
      The date when the cardio-pulmonary resuscitation decision was made.
      Valueset:
      Date and time.
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Location
      Description:
      The location where the cardio-pulmonary resuscitation decision was made.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Coded value
      Description:
      The coded value for location
      Valueset:
      NHS data dictionary: - Organisation data service
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Free text
      Description:
      Free text field to be used if no coded text available
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Cardio-pulmonary resuscitation (CPR) decision
      Description:
      The cardio-pulmonary resuscitation (CPR) decision.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Coded value
      Description:
      The coded value for CPR decision or DNACPR
      Valueset:
      SNOMED CT: - 450475007 | For cardiopulmonary resuscitation (finding) |, 450476008 | Not for cardiopulmonary resuscitation (finding) |
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Free text
      Description:
      Free text field to be used if no code is available
      Valueset:
      Free text
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Date for review
      Description:
      The date for review of CPR decision.
      Valueset:
      Date and time
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Location of document
      Description:
      The location of the CPR decision document
      Valueset:
      Free text or URL
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Performing professional
      Description:
      The professional who made the cardio-pulmonary resuscitation decision.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Name
      Description:
      The name of the professional.
      Valueset:
      Free text.
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Role
      Description:
      The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc
      Valueset:
      FHIR value set :- SDSjobroletype
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Grade
      Description:
      The grade of the professional.
      Valueset:
      Free text
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Speciality
      Description:
      The specialty of the professional e.g. physiotherapy, oncology, mental health etc
      Valueset:
      NHS data dictionary - Activity treatment function code
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Professional identifier
      Description:
      Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.
      Valueset:
      NHS data dictionary : - Professional registration identifier
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Organisation
      Description:
      The name of the organisation the professional works for.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Contact details
      Description:
      Contact details of the professional
      Valueset:
      NHS data dictionary - UK phone number
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Person completing record
      Description:
      Details of the person completing the record.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Name
      Description:
      The name of the person completing the record.
      Valueset:
      Free text.
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Role
      Description:
      The organisational role of the person completing record.
      Valueset:
      FHIR value set :- SDSjobrole
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Grade
      Description:
      The grade of the person completing the record.
      Valueset:
      Free text.
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Specialty
      Description:
      The main specialty of the person completing the record.
      Valueset:
      NHS data dictionary :- Activity treatment function code
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Organisation
      Description:
      The organisation the person completing the record works for.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Professional identifier
      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.
      Valueset:
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Date completed
      Description:
      The date and time the record was completed.
      Valueset:
      Date and time.
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Contact details
      Description:
      Contact details of the person completing the record.
      Valueset:
      NHS data dictionary : - UK telephone number
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Estimated prognosis
      Description:
      Details of the persons estimated prognosis
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Date
      Description:
      The date when the estimated prognosis was made.
      Valueset:
      Date and time
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Location
      Description:
      The location where the estimated prognosis was made.
      Valueset:
      ODS code or free text
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Coded value
      Description:
      The coded value for location
      Valueset:
      NHS data dictionary: - Organisation data service
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Free text
      Description:
      Free text field to be used if no coded text available
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Estimated prognosis
      Description:
      Where a person is terminally ill this is a clinical judgment indicating the anticipated period of time until death e.g. last days, weeks, months or year of life.
      Valueset:
      Free text
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Performing professional
      Description:
      The professional who made the estimated prognosis.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Name
      Description:
      The name of the professional.
      Valueset:
      Free text.
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Role
      Description:
      The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc
      Valueset:
      FHIR value set :- SDSjobroletype
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Grade
      Description:
      The grade of the professional.
      Valueset:
      Free text
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Speciality
      Description:
      The specialty of the professional e.g. physiotherapy, oncology, mental health etc
      Valueset:
      NHS data dictionary - Activity treatment function code
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Professional identifier
      Description:
      Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.
      Valueset:
      NHS data dictionary : - Professional registration identifier
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Organisation
      Description:
      The name of the organisation the professional works for.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Contact details
      Description:
      Contact details of the professional
      Valueset:
      NHS data dictionary - UK phone number
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Person completing record
      Description:
      Details of the person completing the record.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Name
      Description:
      The name of the person completing the record.
      Valueset:
      Free text.
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Role
      Description:
      The organisational role of the person completing record.
      Valueset:
      FHIR value set :- SDSjobrole
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Grade
      Description:
      The grade of the person completing the record.
      Valueset:
      Free text.
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Specialty
      Description:
      The main specialty of the person completing the record.
      Valueset:
      NHS data dictionary :- Activity treatment function code
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Organisation
      Description:
      The organisation the person completing the record works for.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Professional identifier
      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.
      Valueset:
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Date completed
      Description:
      The date and time the record was completed.
      Valueset:
      Date and time.
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Contact details
      Description:
      Contact details of the person completing the record.
      Valueset:
      NHS data dictionary : - UK telephone number
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Awareness of prognosis
      Description:
      Details of the persons awareness of prognosis
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Date
      Description:
      The date when the assessment of the level of awareness of the prognosis was made.
      Valueset:
      Date and time
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Location
      Description:
      The location where the assessment of the level of awareness of the prognosis was made.
      Valueset:
      ODS code and free text
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Coded value
      Description:
      The coded value for location
      Valueset:
      NHS data dictionary: - Organisation data service
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Free text
      Description:
      Free text field to be used if no code is available
      Valueset:
      Free text
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Awareness of prognosis
      Description:
      Description of the level of awareness the person and or their carer/family has regarding their estimated prognosis.
      Valueset:
      Free text
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Performing professional
      Description:
      The professional who made the assessment of the level of awareness of the prognosis.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Name
      Description:
      The name of the professional.
      Valueset:
      Free text.
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Role
      Description:
      The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc
      Valueset:
      FHIR value set :- SDSjobroletype
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Grade
      Description:
      The grade of the professional.
      Valueset:
      Free text
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Speciality
      Description:
      The specialty of the professional e.g. physiotherapy, oncology, mental health etc
      Valueset:
      NHS data dictionary - Activity treatment function code
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Professional identifier
      Description:
      Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.
      Valueset:
      NHS data dictionary : - Professional registration identifier
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Organisation
      Description:
      The name of the organisation the professional works for.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Contact details
      Description:
      Contact details of the professional
      Valueset:
      NHS data dictionary - UK phone number
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Person completing record
      Description:
      Details of the person completing the record.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Name
      Description:
      The name of the person completing the record.
      Valueset:
      Free text.
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Role
      Description:
      The organisational role of the person completing record.
      Valueset:
      FHIR value set :- SDSjobrole
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Grade
      Description:
      The grade of the person completing the record.
      Valueset:
      Free text.
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Specialty
      Description:
      The main specialty of the person completing the record.
      Valueset:
      NHS data dictionary :- Activity treatment function code
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Organisation
      Description:
      The organisation the person completing the record works for.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Professional identifier
      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.
      Valueset:
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Date completed
      Description:
      The date and time the record was completed.
      Valueset:
      Date and time.
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Contact details
      Description:
      Contact details of the person completing the record.
      Valueset:
      NHS data dictionary : - UK telephone number
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Priorities of care
      Description:
      The priorities agreed between the person and their health/care team, where the person has capacity: To get better; please consider all treatment to prolong life. To achieve a balance between getting better and ensuring good quality of life; please consider selected treatments. Comfort; please consider all treatments aimed at symptom control.
      Valueset:
      Free text
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Anticipatory actions
      Description:
      Details of the person's anticipatory actions
      Valueset:
      -
      Cardinality: 0 ... *
      MRO: R
      Information type:
      Name: Date
      Description:
      The date when the anticipatory actions were identified.
      Valueset:
      Date and time
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Location
      Description:
      The location where the anticipatory actions were identified.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Coded value
      Description:
      The coded value for location
      Valueset:
      NHS data dictionary: - Organisation data service
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Free text
      Description:
      Free text field to be used if no coded text available
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Anticipatory actions
      Description:
      Guidance on specific interventions or actions that may be required or should be avoided in specific situations. A statement of anticipatory actions. Usually expressed as: in the event of X do Y.
      Valueset:
      Free text
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Performing professional
      Description:
      The professional who identified the anticipatory actions.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Name
      Description:
      The name of the professional.
      Valueset:
      Free text.
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Role
      Description:
      The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc
      Valueset:
      FHIR value set :- SDSjobroletype
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Grade
      Description:
      The grade of the professional.
      Valueset:
      Free text
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Speciality
      Description:
      The specialty of the professional e.g. physiotherapy, oncology, mental health etc
      Valueset:
      NHS data dictionary - Activity treatment function code
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Professional identifier
      Description:
      Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.
      Valueset:
      NHS data dictionary : - Professional registration identifier
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Organisation
      Description:
      The name of the organisation the professional works for.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Contact details
      Description:
      Contact details of the professional
      Valueset:
      NHS data dictionary - UK phone number
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Person completing record
      Description:
      Details of the person completing the record.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Name
      Description:
      The name of the person completing the record.
      Valueset:
      Free text.
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Role
      Description:
      The organisational role of the person completing record.
      Valueset:
      FHIR value set :- SDSjobrole
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Grade
      Description:
      The grade of the person completing the record.
      Valueset:
      Free text.
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Specialty
      Description:
      The main specialty of the person completing the record.
      Valueset:
      NHS data dictionary :- Activity treatment function code
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Organisation
      Description:
      The organisation the person completing the record works for.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Professional identifier
      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.
      Valueset:
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Date completed
      Description:
      The date and time the record was completed.
      Valueset:
      Date and time.
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Contact details
      Description:
      Contact details of the person completing the record.
      Valueset:
      NHS data dictionary : - UK telephone number
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Anticipatory medicines/equipment
      Description:
      Details of the persons availability or location regarding their anticipatory medicines/equipment.
      Valueset:
      -
      Cardinality: 0 ... *
      MRO: R
      Information type:
      Name: Date
      Description:
      The date when the statement regarding anticipatory medicines/equipment was made.
      Valueset:
      Date and time
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Location
      Description:
      The location where the statement regarding anticipatory medicines/equipment was made.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Coded value
      Description:
      The coded value for location
      Valueset:
      NHS data dictionary: - Organisation data service
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Free text
      Description:
      Free text field to be used if no coded text available
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Anticipatory medicines/equipment
      Description:
      A statement regarding the availability or location of the anticipatory medicines/equipment.
      Valueset:
      Free text
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Performing professional
      Description:
      The professional who made the statement regarding anticipatory medicines/equipment was made.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Name
      Description:
      The name of the professional.
      Valueset:
      Free text.
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Role
      Description:
      The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc
      Valueset:
      FHIR value set :- SDSjobroletype
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Grade
      Description:
      The grade of the professional.
      Valueset:
      Free text
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Speciality
      Description:
      The specialty of the professional e.g. physiotherapy, oncology, mental health etc
      Valueset:
      NHS data dictionary - Activity treatment function code
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Professional identifier
      Description:
      Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.
      Valueset:
      NHS data dictionary : - Professional registration identifier
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Organisation
      Description:
      The name of the organisation the professional works for.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Contact details
      Description:
      Contact details of the professional
      Valueset:
      NHS data dictionary - UK phone number
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Person completing record
      Description:
      Details of the person completing the record.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Name
      Description:
      The name of the person completing the record.
      Valueset:
      Free text.
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Role
      Description:
      The organisational role of the person completing record.
      Valueset:
      FHIR value set :- SDSjobrole
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Grade
      Description:
      The grade of the person completing the record.
      Valueset:
      Free text.
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Specialty
      Description:
      The main specialty of the person completing the record.
      Valueset:
      NHS data dictionary :- Activity treatment function code
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Organisation
      Description:
      The organisation the person completing the record works for.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Professional identifier
      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.
      Valueset:
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Date completed
      Description:
      The date and time the record was completed.
      Valueset:
      Date and time.
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Contact details
      Description:
      Contact details of the person completing the record.
      Valueset:
      NHS data dictionary : - UK telephone number
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Preferred place of death
      Description:
      Details of the person's preferred place of death
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Date
      Description:
      The date when the preferred place of death was identified.
      Valueset:
      Date and time
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Location
      Description:
      The location where the preferred place of death was identified.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Coded value
      Description:
      The coded value for location
      Valueset:
      NHS data dictionary: - Organisation data service
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Free text
      Description:
      Free text field to be used if no code is available
      Valueset:
      Free text
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Preferred place of death 1st
      Description:
      The preferences that a person has identified as their preferred place to die.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Name of the place
      Description:
      The name of the preferred place of death
      Valueset:
      Free text
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Type of place
      Description:
      The type of preferred place of death
      Valueset:
      SCC11580 code : - 10: Hospital (Acute/Community/Other)20: Private residence21: Patient's own home22: Other private residence (eg relatives home, carers home)30: Hospice (inpatient specialist palliative care)40: Care Home50: Other (free text eg secure and detained settings)517111000000103, Preferred place of death: patient unable to express preference 517131000000106, Preferred place of death: discussion not appropriate766391000000108, Preferred place of death: patient declined discussion517161000000101, Preferred place of death: patient undecided
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Preferred place of death 2nd
      Description:
      The preferences that a person has identified as their preferred place to die.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Name of the place
      Description:
      The name of the preferred place of death
      Valueset:
      Free text
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Type of place
      Description:
      The type of preferred place of death
      Valueset:
      SCC11580 code : - 10: Hospital (Acute/Community/Other)20: Private residence21: Patient's own home22: Other private residence (eg relatives home, carers home)30: Hospice (inpatient specialist palliative care)40: Care Home50: Other (free text eg secure and detained settings)517111000000103, Preferred place of death: patient unable to express preference 517131000000106, Preferred place of death: discussion not appropriate766391000000108, Preferred place of death: patient declined discussion517161000000101, Preferred place of death: patient undecided
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Performing professional
      Description:
      The professional who identified the preferred place of death.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Name
      Description:
      The name of the professional.
      Valueset:
      Free text.
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Role
      Description:
      The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc
      Valueset:
      FHIR value set :- SDSjobroletype
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Grade
      Description:
      The grade of the professional.
      Valueset:
      Free text
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Speciality
      Description:
      The specialty of the professional e.g. physiotherapy, oncology, mental health etc
      Valueset:
      NHS data dictionary - Activity treatment function code
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Professional identifier
      Description:
      Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.
      Valueset:
      NHS data dictionary : - Professional registration identifier
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Organisation
      Description:
      The name of the organisation the professional works for.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Contact details
      Description:
      Contact details of the professional
      Valueset:
      NHS data dictionary - UK phone number
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Person completing record
      Description:
      Details of the person completing the record.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Name
      Description:
      The name of the person completing the record.
      Valueset:
      Free text.
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Role
      Description:
      The organisational role of the person completing record.
      Valueset:
      FHIR value set :- SDSjobrole
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Grade
      Description:
      The grade of the person completing the record.
      Valueset:
      Free text.
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Specialty
      Description:
      The main specialty of the person completing the record.
      Valueset:
      NHS data dictionary :- Activity treatment function code
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Organisation
      Description:
      The organisation the person completing the record works for.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Professional identifier
      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.
      Valueset:
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Date completed
      Description:
      The date and time the record was completed.
      Valueset:
      Date and time.
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Contact details
      Description:
      Contact details of the person completing the record.
      Valueset:
      NHS data dictionary : - UK telephone number
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Preferred place of care
      Description:
      Details of the persons preferred place of care
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Date
      Description:
      The date when the preferred place of care was identified.
      Valueset:
      Date and time
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Location
      Description:
      The location where the preferred place of care was identified.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Coded value
      Description:
      The coded value for location
      Valueset:
      NHS data dictionary: - Organisation data service
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Free text
      Description:
      Free text field to be used if no code is available
      Valueset:
      Free text
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Preferred place of care
      Description:
      The preferences that the person has identified as their preferred place to receive care.
      Valueset:
      Free text
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Performing professional
      Description:
      The professional who identified the preferred place of care.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Name
      Description:
      The name of the professional.
      Valueset:
      Free text.
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Role
      Description:
      The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc
      Valueset:
      FHIR value set :- SDSjobroletype
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Grade
      Description:
      The grade of the professional.
      Valueset:
      Free text
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Speciality
      Description:
      The specialty of the professional e.g. physiotherapy, oncology, mental health etc
      Valueset:
      NHS data dictionary - Activity treatment function code
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Professional identifier
      Description:
      Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.
      Valueset:
      NHS data dictionary : - Professional registration identifier
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Organisation
      Description:
      The name of the organisation the professional works for.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Contact details
      Description:
      Contact details of the professional
      Valueset:
      NHS data dictionary - UK phone number
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Person completing record
      Description:
      Details of the person completing the record.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Name
      Description:
      The name of the person completing the record.
      Valueset:
      Free text.
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Role
      Description:
      The organisational role of the person completing record.
      Valueset:
      FHIR value set :- SDSjobrole
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Grade
      Description:
      The grade of the person completing the record.
      Valueset:
      Free text.
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Specialty
      Description:
      The main specialty of the person completing the record.
      Valueset:
      NHS data dictionary :- Activity treatment function code
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Organisation
      Description:
      The organisation the person completing the record works for.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Professional identifier
      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.
      Valueset:
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Date completed
      Description:
      The date and time the record was completed.
      Valueset:
      Date and time.
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Contact details
      Description:
      Contact details of the person completing the record.
      Valueset:
      NHS data dictionary : - UK telephone number
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Documents (including correspondence and images)
      Description:
      Details about documents related to the person.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Documents
      Description:
      This is the documents 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.
      Valueset:
      -
      Cardinality: 0 ... *
      MRO: R
      Information type:
      Name: Date
      Description:
      The date and time the document was created.
      Valueset:
      Date and time
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Performing professional
      Description:
      The professional who authored the document.
      Valueset:
      Free text.
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Name
      Description:
      The name of the professional.
      Valueset:
      Free text.
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Role
      Description:
      The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc
      Valueset:
      FHIR value set :- SDSjobroletype
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Grade
      Description:
      The grade of the professional.
      Valueset:
      Free text
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Speciality
      Description:
      The specialty of the professional e.g. physiotherapy, oncology, mental health etc
      Valueset:
      NHS data dictionary - Activity treatment function code
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Professional identifier
      Description:
      Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.
      Valueset:
      NHS data dictionary : - Professional registration identifier
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Organisation
      Description:
      The name of the organisation the professional works for.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Contact details
      Description:
      Contact details of the professional
      Valueset:
      NHS data dictionary - UK phone number
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Documentation location
      Description:
      The location of the document
      Valueset:
      Free text or URL
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Confidentiality
      Description:
      The code specifying the level of confidentiality of the document.
      Valueset:

      FHIR value set : - Confidentiality

      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Class
      Description:
      The document type e.g. report, summary, images, treatment plan, patient preferences, workflow
      Valueset:
      Free text.
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Document title
      Description:
      The title of the document.
      Valueset:
      Free text
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Document name
      Description:
      The name of the document. This should align to the PRSB document naming standard. Where the document is a KOS document this field (designated typeCode) is used to carry the DICOM Imaging procedure: This attribute shall be populated by the XDS-I Imaging Document Source from a code in the Procedure Code Sequence (0008,1032) of the performed procedure with which the document is associated. Values may be found in a suitable DICOM browser
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Document MIME type
      Description:
      MIME type of the document e.g. application, pdf, audio, jpeg
      Valueset:
      Free text
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Person completing record
      Description:
      Details of the person completing the record.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Name
      Description:
      The name of the person completing the record.
      Valueset:
      Free text.
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Role
      Description:
      The organisational role of the person completing record.
      Valueset:
      FHIR value set :- SDSjobrole
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Grade
      Description:
      The grade of the person completing the record.
      Valueset:
      Free text.
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Specialty
      Description:
      The main specialty of the person completing the record.
      Valueset:
      NHS data dictionary :- Activity treatment function code
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Organisation
      Description:
      The organisation the person completing the record works for.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Professional identifier
      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.
      Valueset:
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Date completed
      Description:
      The date and time the record was completed.
      Valueset:
      Date and time.
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Contact details
      Description:
      Contact details of the person completing the record.
      Valueset:
      NHS data dictionary : - UK telephone number
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Service
      Description:
      The high level imaging speciality code e.g. (R-3027B, SRT, “Radiology”)
      Valueset:
      SNOMED CT or free text 999000381000000107 |Correspondence care setting type simple reference set (foundation metadata concept)|
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Comments
      Description:
      Comments associated with the document.
      Valueset:
      Free text
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Additional information required for images.
      Description:
      Additional information required for images.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Image procedure
      Description:
      The procedure used to capture the image
      Valueset:
      Free text
      Using DICOM code set https://dicom.innolitics.com/ciods
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Image procedure date
      Description:
      The date and time the image procedure was performed.
      Valueset:
      Date and time
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Performing professional
      Description:
      The professional who performed the image procedure.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Name
      Description:
      The name of the professional.
      Valueset:
      Free text.
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Role
      Description:
      The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc
      Valueset:
      FHIR value set :- SDSjobroletype
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Grade
      Description:
      The grade of the professional.
      Valueset:
      Free text
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Speciality
      Description:
      The specialty of the professional e.g. physiotherapy, oncology, mental health etc
      Valueset:
      NHS data dictionary - Activity treatment function code
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Professional identifier
      Description:
      Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.
      Valueset:
      NHS data dictionary : - Professional registration identifier
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Organisation
      Description:
      The name of the organisation the professional works for.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Contact details
      Description:
      Contact details of the professional
      Valueset:
      NHS data dictionary - UK phone number
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Images
      Description:
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Image capture date
      Description:
      The date and time when the image was captured.
      Valueset:
      Date and time
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Image ID
      Description:
      A unique image identifier generated by the system.
      Valueset:
      Free text
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Image location
      Description:
      The URL for the image
      Valueset:
      Free text
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Format code
      Description:
      The format code of the document which provides information on how to display the document.
      Valueset:
      Free text
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Event code list
      Description:
      The type of image (acquisition modality) and the anatomical site imaged.
      Valueset:
      DICOM code
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Person completing record
      Description:
      Details of the person completing the record.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Name
      Description:
      The name of the person completing the record.
      Valueset:
      Free text.
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Role
      Description:
      The organisational role of the person completing record.
      Valueset:
      FHIR value set :- SDSjobrole
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Grade
      Description:
      The grade of the person completing the record.
      Valueset:
      Free text.
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Specialty
      Description:
      The main specialty of the person completing the record.
      Valueset:
      NHS data dictionary :- Activity treatment function code
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Organisation
      Description:
      The organisation the person completing the record works for.
      Valueset:
      -
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Professional identifier
      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.
      Valueset:
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Date completed
      Description:
      The date and time the record was completed.
      Valueset:
      Date and time.
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Contact details
      Description:
      Contact details of the person completing the record.
      Valueset:
      NHS data dictionary : - UK telephone number
      Cardinality: 0 ... 1
      MRO: R
      Information type:
      Name: Comments
      Description:
      Comments associated with the imaging
      Valueset:
      Free text
      Cardinality: 0 ... 1
      MRO
      Name
      Description
      M
      Person demographics
      The person's details and contact information.
      M
      Person name
      Details of the person's name
      R
      Person first name
      The first name(s) of the person. This includes middle names.
      R
      Person family name
      The family name or surname of the person
      R
      Person preferred name
      The name by which a person wishes to be addressed. The preferred name volunteered by the person or a preferred name given by PDS that the person has asked to be called by.
      R
      Title
      Person's title
      R
      Person name suffix
      A textual suffix that may be added to the end of a PERSON's name, for example, OBE, MBE, BSc, JP, GM
      R
      Person full name
      The full name of the person in text representation.
      M
      Date of birth
      The date of birth of the person.
      R
      Gender
      The person's stated gender.
      R
      Ethnicity
      The ethnicity of the person as specified by the person.
      R
      Religion
      The religious affiliation as specified by the person.
      R
      Sex
      The person’s phenotypic sex. Determines how the person will be treated clinically.
      R
      NHS number
      The unique identifier for a person within the NHS in England and Wales.
      R
      Other identifier
      Country specific or local identifier, e.g. Community Health Index (CHI) in Scotland.
      R
      Person's address
      Person’s usual place of residence, and where relevant temporary and correspondence addresses.
      R
      Address line 1
      Person's first line of address.
      R
      Address line 2
      Person's second line of address.
      R
      Address line 3
      Person's third line of address.
      R
      Address line 4
      Person's fourth line of address.
      R
      Address line 5
      Person's fifth line of address.
      R
      Postcode
      The person's postcode.
      R
      Place of birth
      The country of birth of the person.
      R
      Organ and tissue donation
      Whether the person has given consent for organ and/or tissue donation or opted out of automatic donation where applicable. This is information provided by the national register.
      R
      GP practice
      Details of the person's GP practice.
      R
      GP practice record entry
      This is an GP practice record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items
      R
      GP name
      The name of the person's GP. If the person is registered with a GP practice, their usual GP name will be something volunteered by the person or their representative.
      R
      GP practice details
      Name and address of the person's registered GP practice Registered GP practice details are available from the Patient Demographics Service (PDS), or volunteered from the person or their representative. Include details of the practice name and address.
      R
      GP practice identifier
      The identifier of the registered GP practice.
      R
      About me
      About me
      R
      About me
      This is a record of the things that a person feels it is important to communicate about their needs, strengths, values, concerns and preferences to others providing support and care.
      R
      What is most important to me
      A description of what is most important to you
      Emergency Information : - Include any essential information that any professional in health and social care should know about the you in any situation, including emergencies.
      Other Information : -This could include : - Values, Spirituality/religion, Ethnicity, Culture, Pets, Goals and aspirations, Meaningful activities including leisure activities, visiting places, sport and exercise, listening to music, employment, education, volunteering
      R
      People who are important to me
       Details of who is important to you and why. They could be family members, carers, friends, members of staff etc. Include how you want the people important to you to be engaged and involved in your care and support in both emergency and normal situations. Include how you stay connected to the people important to you. Who should not be contacted or consulted about your care and support and why, if you wish to say
      R
      How I communicate and how to communicate with me

      A description of how you communicate normally including any communication aids you use, for example a hearing aid.

      • Include your preferred language of communication, if your first language is not English.
      • Include how you would communicate when you are in pain or distress.
      • Include how you communicate choices.
      • Include how you give feedback or raise a concern.
      • Include how you like to receive information

      Describe how you would like others to engage and communicate with you, including how you would like to be addressed.

      R
      My wellness

      A description covering what you are able to do, how you engage with others and how you feel on a typical day through to on a day when you are unwell or really unwell.

      • Include any causes that might result in you becoming unwell and strategies for avoiding or addressing the causes. For example, not drinking enough water could cause constipation.
      • Include any signs that indicate you might be becoming unwell.
      • On a bad day describe what is different about what you are able to do, how you engage with others and how you feel.
      • Include how your everyday life is affected by any medical conditions e.g. dementia and any symptoms e.g. itchiness, cough, pain and how you manage those conditions.
      • Include past health issues or experiences that need to be considered
      • Include your wellbeing and lifestyle goals and aspirations
      R
      Please do and please don't

      A description of things you want someone supporting you to do or not to do.

      For example, this might include: - Talk to me not to my carer, remind me to take my medication, encourage me to wash my hands regularly, explain to me what is happening and why, respond to my communication.

      A description of things you do not want someone supporting for you to do. For example, this might include: - Discussing or asking questions about certain topics, making assumptions about something, providing support when it is not wanted, talking to you in a certain way.

      R
      How and when to support me

      A description of how and when you want someone caring for you to support you.

      This could include support needs in an emergency situation (for example taking blood)

      This could include support you need to maintain important routines or to carry out particular activities, for example: - Personal care routines, Eating and drinking, Bedtime routines, Taking medications, Moving and transitioning

      This could also include support needed with:- wearing glasses/hearing aids/false teeth etc, making informed choices or understanding dangers and risks, managing your emotions, moods and behaviours, memory or confusion.

      Include how your support needs change in different environments. Include any triggers that might result in you needing further support and strategies for avoiding or addressing the triggers. Include how you want the support to be provided.

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      Also worth knowing about me

      A description of what is also worth knowing about you for people caring or supporting you.

      This could include a short history of your life (where you have worked, where you lived, important events in your life, important people in your past life).

      This could include a short profile of your current life:- your work / study, your aspirations, your skills, your networks, things you like e.g. particular foods, places, a football team and things you like to talk about, things you dislike

      This could also include any care and support preferences that have not been included elsewhere.

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      Date
      This is a record of the date that this information was last updated.
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      Supported to write this by
      Where relevant, this is a record of name, relationship/role and contact details of the individual who supported the person to write this section e.g. carer, family member, advocate, professional.
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      Individual requirements
      The individual requirements of the person.
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      Reasonable adjustment
      A record of reasonable adjustments that must be provided by the service to comply with the Equality Act 2010.
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      Reasonable adjustment record entry
      This is a reasonable adjustment record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items
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      Location
      The location where the reasonable adjustment was identified.
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      Coded value
      The coded value for location.
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      Free text
      Free text field to be used if no code is available
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      Reasonable adjustment flag

      Under the Equality Act 2010, organisations have a legal duty to make changes in their approach or provision to ensure that services are as accessible to people with disabilities as they are for everybody else. These changes are called reasonable adjustments.

      Reasonable adjustments can mean alterations to buildings by providing lifts, wide doors, ramps and tactile signage, but may also mean changes to policies, procedures and staff training to ensure that services work equally well for people with physical or sensory disabilities, learning disabilities or long-term conditions such as dementia.

      Other adjustments include longer appointments, providing easy read materials or communications via a carer. This legal duty is anticipatory which means a service should know about a person’s need for adjustments when they are referred or present for care. For this to happen, and for optimum care to be delivered, adjustments need to be recorded and shared across the NHS.

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      Reasonable adjustment
      The reasonable adjustment required e.g. requires specific contact method, requires communication professional
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      Coded value
      The coded value for reasonable adjustment
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      Free text
      Free text field to be used if no code is available
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      Reasonable adjustment additional detail
      Further detail about the support required and the consequence of not providing it.
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      Date
      The date the reasonable adjustment was identified.
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      Performing professional
      The professional who confirmed the need for the reasonable adjustment.
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      Name
      The name of the professional.
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      Role
      The role the professional has in relation to the person.
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      Grade
      The grade of the professional.
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      Speciality
      The specialty of the professional.
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      Professional identifier
      Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.
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      Organisation
      The name of the organisation the professional works for.
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