MRO
Information
Type
Type
Name
Description
Value Sets
Implementation
Guidance
Guidance
Cardinality
MRO: M
Information type:
Description:
The person's details and contact information.
Valueset:
-
Cardinality: 1 ... 1
MRO: M
Information type:
Description:
Details of the person's name
Valueset:
-
Cardinality: 1 ... 1
MRO: R
Information type:
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:
Description:
The family name or surname of the person
Valueset:
NHS data dictionary : - Person family name
Cardinality: 0 ... 1
MRO: R
Information type:
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:
Description:
Person's title
Valueset:
NHS data dictionary: - Person title
Cardinality: 0 ... 1
MRO: R
Information type:
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:
Description:
The full name of the person in text representation.
Valueset:
NHS data dictionary :- Patient full name
Cardinality: 0 ... 1
MRO: M
Information type:
Description:
The date of birth of the person.
Valueset:
NHS data dictionary:- Person birth date
Cardinality: 1 ... 1
MRO: R
Information type:
Description:
The person's stated gender.
Valueset:
NHS data dictionary :- Person stated gender code
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The ethnicity of the person as specified by the person.
Valueset:
NHS data dictionary :- Ethnic category
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The religious affiliation as specified by the person.
Valueset:
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The person’s phenotypic sex. Determines how the person will be treated clinically.
Valueset:
NHS data dictionary:- person phenotypic sex classification
Cardinality: 0 ... 1
MRO: R
Information type:
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:
Description:
Country specific or local identifier, e.g. Community Health Index (CHI) in Scotland.
Valueset:
NHS data dictionary: - Local patient identifier(extended), Health and care number (NI only), Community health index number (Scotland only)
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Person’s usual place of residence, and where relevant temporary and correspondence addresses.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Person's first line of address.
Valueset:
NHS data dictionary :- Address line 1
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Person's second line of address.
Valueset:
NHS data dictionary :- Address line 2
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Person's third line of address.
Valueset:
NHS data dictionary : - Address line 3
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Person's fourth line of address.
Valueset:
NHS data dictionary : - Address line 4
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Person's fifth line of address.
Valueset:
NHS data dictionary : - Address line 5
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The person's postcode.
Valueset:
NHS data dictionary :- Postcode of usual address
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The country of birth of the person.
Valueset:
NHS data dictionary :- Country code (birth)
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Details of the person's GP practice.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
Description:
The identifier of the registered GP practice.
Valueset:
NHS data dictionary : - General medical practice code (patient registration)
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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
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:
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:
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:
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:
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:
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:
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:
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:
Description:
The individual requirements of the person.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
Description:
The location where the reasonable adjustment was identified.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The coded value for location.
Valueset:
NHS Data dictionary : - Organisation data service code
Cardinality: 0 ... 1
MRO: R
Information type:
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:
Description:
The reasonable adjustment required e.g. requires specific contact method, requires communication professional
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
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
^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:
Description:
The professional who confirmed the need for the reasonable adjustment.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The role the professional has in relation to the person.
Valueset:
FHIR value set : - sdsjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The specialty of the professional.
Valueset:
NHS data dictionary - Main specialty code
Cardinality: 0 ... 1
MRO: R
Information type:
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:
Description:
Contact details of the professional
Valueset:
NHS data dictionary - UK phone number
Cardinality: 0 ... 1
MRO: R
Information type:
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:
Description:
The organisational role of the person completing record.
Valueset:
FHIR value set :- SDSjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
NHS data dictionary :- Professional registration identifier
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Contact details of the person completing the record.
Valueset:
NHS data dictionary : - UK telephone number
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
A record of any impairments for the person relating to reasonable adjustments.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
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:
Description:
The location where the impairment was identified.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The coded value for location.
Valueset:
NHS data dictionary: - Organisation code service
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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.
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:
Description:
The professional who confirmed the impairment.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
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:
Description:
Contact details of the professional
Valueset:
NHS data dictionary - UK phone number
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
A record of the details of the person that entered the impairment and the date on which it was entered.
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:
Description:
The organisational role of the person completing record.
Valueset:
FHIR value set :- SDSjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
NHS data dictionary :- Professional registration identifier
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Contact details of the person completing the record.
Valueset:
NHS data dictionary : - UK telephone number
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Details of the person's mobility needs.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The location where the mobility needs were identified.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The coded value for location.
Valueset:
NHS data dictionary : - Organisation data service
Cardinality: 0 ... 1
MRO: R
Information type:
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:
Description:
The professional who identified the mobility needs.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
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:
Description:
Contact details of the professional
Valueset:
NHS data dictionary - UK phone number
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Details of the person completing the record.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The organisational role of the person completing record.
Valueset:
FHIR value set :- SDSjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
NHS data dictionary :- Professional registration identifier
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Contact details of the person completing the record.
Valueset:
NHS data dictionary : - UK telephone number
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Details of any other individual requirements the person may have
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The location where the other individual requirements were identified.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The coded value for location.
Valueset:
NHS data dictionary : - Organisation service code
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The professional who identified the other individual requirements.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
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:
Description:
Contact details of the professional
Valueset:
NHS data dictionary - UK phone number
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Details of the person completing the record.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The organisational role of the person completing record.
Valueset:
FHIR value set :- SDSjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
NHS data dictionary :- Professional registration identifier
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Contact details of the person completing the record.
Valueset:
NHS data dictionary : - UK telephone number
Cardinality: 0 ... 1
MRO: R
Information type:
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:
Description:
Details of the person completing the record.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The organisational role of the person completing record.
Valueset:
FHIR value set :- SDSjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
NHS data dictionary :- Professional registration identifier
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Contact details of the person completing the record.
Valueset:
NHS data dictionary : - UK telephone number
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The legal information relating to the person.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Details of the persons mental capacity assessment
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The location where the mental capacity assessment was made.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The coded value for location
Valueset:
NHS data dictionary : - Organisation code
Cardinality: 0 ... 1
MRO: R
Information type:
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:
Description:
The professional who made the mental capacity assessment.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
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:
Description:
The name of the organisation the professional works for.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The coded value for location
Valueset:
NHS data dictionary: - Organisation data service
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Contact details of the professional
Valueset:
NHS data dictionary - UK phone number
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Details of the person completing the record.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The organisational role of the person completing record.
Valueset:
FHIR value set :- SDSjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
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:
Description:
The organisation the person completing the record works for.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The coded value for location
Valueset:
NHS data dictionary : - Organisation data service
Cardinality: 0 ... 1
MRO: R
Information type:
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:
NHS data dictionary :- Professional registration identifier
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Contact details of the person completing the record.
Valueset:
NHS data dictionary : - UK telephone number
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Details of the person's LPA record or equivalent
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The location where the LPA was given
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The coded value for location
Valueset:
Cardinality: 0 ... 1
MRO: R
Information type:
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:
Description:
The contact details of the LPA
Valueset:
NHS data dictionary:- UK telephone number
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The professional who took the details of the LPA or equivalent
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
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:
Description:
Contact details of the professional
Valueset:
NHS data dictionary - UK phone number
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Details of the person who took the LPA.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The organisational role of the person completing record.
Valueset:
FHIR value set :- SDSjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
NHS data dictionary :- Professional registration identifier
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Contact details of the person completing the record.
Valueset:
NHS data dictionary : - UK telephone number
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Details of the person's Deprivation of Liberty Safeguards (DoLS) or equivalent
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The professional who applied for the DOLs.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
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:
Description:
Contact details of the professional
Valueset:
NHS data dictionary - UK phone number
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Details of the persons mental health act record
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
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:
Description:
The coded value for location
Valueset:
Cardinality: 0 ... 1
MRO: R
Information type:
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:
Description:
The coded value for mental health act
Valueset:
NHS data dictionary: - Mental health act legal status classification code
Cardinality: 0 ... 1
MRO: R
Information type:
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:
Description:
The professional who made the decision to detain the person under the mental health act.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
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:
Description:
Contact details of the professional
Valueset:
NHS data dictionary - UK phone number
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Details of the person completing the record.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The organisational role of the person completing record.
Valueset:
FHIR value set :- SDSjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
NHS data dictionary :- Professional registration identifier
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Contact details of the person completing the record.
Valueset:
NHS data dictionary : - UK telephone number
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Details of the person's ADRT status.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The location where the ADRT was recorded.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The coded value of location
Valueset:
NHS data dictionary : - Organisation data service
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
Description:
The professional who recorded the ADRT
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
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:
Description:
Contact details of the professional
Valueset:
NHS data dictionary - UK phone number
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Details of the person who recorded the ADRT.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The organisational role of the person completing record.
Valueset:
FHIR value set :- SDSjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
NHS data dictionary :- Professional registration identifier
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Contact details of the person completing the record.
Valueset:
NHS data dictionary : - UK telephone number
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The safeguarding details of the person.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Details of safeguarding concerns
Valueset:
-
Cardinality: 0 ... *
MRO: R
Information type:
Description:
The location where the safeguarding concerns were identified.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The coded value of location
Valueset:
NHS data dictionary : - Organisation code
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Identified safeguarding concerns.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The professional who identified the safeguarding concerns.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
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:
Description:
Contact details of the professional
Valueset:
NHS data dictionary - UK phone number
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Details of the person completing the record.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The organisational role of the person completing record.
Valueset:
FHIR value set :- SDSjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
NHS data dictionary :- Professional registration identifier
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Contact details of the person completing the record.
Valueset:
NHS data dictionary : - UK telephone number
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The details of the person’s professional contacts.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
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:
Description:
The name of the organisation.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The coded value for location
Valueset:
NHS data dictionary : - Organisation data service
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The details of the individual's personal contacts.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
Description:
The details of the referral.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
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:
Description:
The details of the referrer.
This could be the person, GP surgery, department, specialty, sub-specialty, educational institution, mental health team etc.
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:
Description:
Role of the referrer.
Valueset:
FHIR value set : - sdsjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The specialty of the referrer.
Valueset:
NHS data dictionary - Activity treatment function code
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The service of the referrer.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The organisation of the referrer.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The coded value for organisation code
Valueset:
NHS data dictionary : - Organisation data service
Cardinality: 0 ... 1
MRO: R
Information type:
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
- Fax
- Phone
- Secure Messaging
- Secure Email
- Letter
- NHS E-Referral Service
- Self referral
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The details of the clinical urgency of referral
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
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.
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:
Description:
Role of person where the referral is to be sent to.
Valueset:
FHIR value set : - sdsjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
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:
Description:
The service of where the referral is sent to.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The organisation of where the referral is to be sent.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The coded value for organisation
Valueset:
NHS data dictionary :- Organisation data service
Cardinality: 0 ... 1
MRO: R
Information type:
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:
Description:
The details of the person’s contact with a professional.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
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:
Description:
The location where the contact took place.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The coded value for location
Valueset:
NHS data dictionary : - Organisation service code
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The professional that saw the person.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The role of the person providing the service.
Valueset:
FHIR values set : - sdsjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
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:
Description:
The role of the responsible professional
Valueset:
FHIR value set : - sdsjobrole
Cardinality: 0 ... 1
MRO: R
Information 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:
Description:
Consultation method used e.g. face to face, telephone
Valueset:
NHS data dictionary - Consultation medium
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
Description:
The role of the professional present.
Valueset:
FHIR value set : - sdsjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
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:
Description:
Admission details
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
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:
Description:
The hospital the person was admitted to.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The coded value for admission to
Valueset:
NHS data dictionary : - Organisations code of provider
Cardinality: 0 ... 1
MRO: R
Information type:
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:
Description:
The role of the responsible consultant.
Valueset:
FHIR value set: - sdsjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
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:
Description:
How the person was admitted to hospital e.g. elective, emergency, maternity, transfer etc.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The coded value for admission method
Valueset:
NHS data dictionary : - Admission method
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Whether the person was admitted as informal or formal/detained.
Valueset:
NHS data dictionary : - Mental health act legal status classification code
Cardinality: 0 ... 1
MRO: R
Information type:
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:
Description:
The coded value of source of admission
Valueset:
NHS data dictionary :- Source of admission
Cardinality: 0 ... 1
MRO: R
Information type:
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:
Description:
Relationship of individual accompanying the person.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The coded value for relationship to person.
Valueset:
FHIR value set: -
Relationship type
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The specialty e.g. physiotherapy, oncology, mental health etc
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The coded value for specialty
Valueset:
NHS data dictionary :- Activity treatment function code
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Discharge details
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
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:
Description:
The hospital the person was discharged from.
Valueset:
NHS data dictionary : - Organisation data service
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The consultant responsible for the person at time of discharge.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The role of the discharging consultant
Valueset:
FHIR value set : - sdsjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
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:
Description:
The coded value for discharge method
Valueset:
NHS data dictionary : - Discharge method
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The specialty of the consultant responsible for the person at the time of discharge.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The coded value for discharge speciality
Valueset:
NHS data dictionary : - Activity treatment function code
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Whether the person was discharged as informal or formal/detained.
Valueset:
NHS data dictionary : - Mental health act classification code
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
Description:
Details of future appointments.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
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:
Description:
The location of the appointment.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The coded value for location
Valueset:
NHS data dictionary : - Organisation data service
Cardinality: 0 ... 1
MRO: R
Information type:
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:
Description:
The name and role of the professional e.g. consultant, care worker, nurse consultant.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The role of the professional seeing the person.
Valueset:
FHIR value set : - sdsjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Investigation results
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
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:
Description:
The professional who performed the investigation.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
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:
Description:
Contact details of the professional
Valueset:
NHS data dictionary - UK phone number
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The location where the investigation took place.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The investigation performed.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
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:
Description:
A structured set of information for each investigation result.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Details of the person completing the record.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The organisational role of the person completing record.
Valueset:
FHIR value set :- SDSjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
NHS data dictionary :- Professional registration identifier
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Contact details of the person completing the record.
Valueset:
NHS data dictionary : - UK telephone number
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Details of any investigations requested
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
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:
Description:
The location where the investigation was requested.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The coded value for location
Valueset:
NHS data dictionary: - Organisation data service
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The professional who requested the investigation.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
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:
Description:
Contact details of the professional
Valueset:
NHS data dictionary - UK phone number
Cardinality: 0 ... 1
MRO: R
Information type:
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:
Description:
Details of the person completing the record.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The organisational role of the person completing record.
Valueset:
FHIR value set :- SDSjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
NHS data dictionary :- Professional registration identifier
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Contact details of the person completing the record.
Valueset:
NHS data dictionary : - UK telephone number
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Examination findings
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
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:
Description:
The professional who performed the examiniation.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
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:
Description:
Contact details of the professional
Valueset:
NHS data dictionary - UK phone number
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The location where the examination was performed.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The coded value for location
Valueset:
NHS data dictionary : - Organisation data service
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The record of findings from the examinations performed.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
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:
Description:
Details of the person completing the record.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The organisational role of the person completing record.
Valueset:
FHIR value set :- SDSjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
NHS data dictionary :- Professional registration identifier
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Contact details of the person completing the record.
Valueset:
NHS data dictionary : - UK telephone number
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Details of the person's assessments
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
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:
Description:
The location where the assessment was done.
Valueset:
ODS code or free text.
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The coded value for location
Valueset:
NHS data dictionary: - Organisation data service
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Details of the structured assessment.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The professional who did the assessment.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
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:
Description:
Contact details of the professional
Valueset:
NHS data dictionary - UK phone number
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Details of the person completing the record.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The organisational role of the person completing record.
Valueset:
FHIR value set :- SDSjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
NHS data dictionary :- Professional registration identifier
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Contact details of the person completing the record.
Valueset:
NHS data dictionary : - UK telephone number
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Details of any risks related to the person.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Details of the persons risk to self
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The location where the risk was identified.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The coded value for location
Valueset:
NHS data dictionary : - Organisation service code
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The professional who identified the risk.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
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:
Description:
Contact details of the professional
Valueset:
NHS data dictionary - UK phone number
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Details of the person completing the record.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The organisational role of the person completing record.
Valueset:
FHIR value set :- SDSjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
NHS data dictionary :- Professional registration identifier
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Contact details of the person completing the record.
Valueset:
NHS data dictionary : - UK telephone number
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Details of the person's risk to others
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The location where the risk to others was identified.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The coded value for location
Valueset:
NHS data dictionary : - Organisation data service
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The professional who identifies the risk to others.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
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:
Description:
Contact details of the professional
Valueset:
NHS data dictionary - UK phone number
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Details of the person completing the record.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The organisational role of the person completing record.
Valueset:
FHIR value set :- SDSjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
NHS data dictionary :- Professional registration identifier
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Contact details of the person completing the record.
Valueset:
NHS data dictionary : - UK telephone number
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Risks to the person from an identified individual e.g. family member etc.
Valueset:
Free Text.
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The location where the risk from others was identified.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The coded value for location
Valueset:
NHS data dictionary : - Organisation data service
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The professional who identified the risk from others.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
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:
Description:
Contact details of the professional
Valueset:
NHS data dictionary - UK phone number
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Details of the person completing the record.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The organisational role of the person completing record.
Valueset:
FHIR value set :- SDSjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
NHS data dictionary :- Professional registration identifier
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Contact details of the person completing the record.
Valueset:
NHS data dictionary : - UK telephone number
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Details of the risks the person poses to themselves from accidents.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The location where the risk of accidents was identified.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The coded value for location
Valueset:
NHS data dictionary : - Organisation data service
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The professional who identified the risk of accidents.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
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:
Description:
Contact details of the professional
Valueset:
NHS data dictionary - UK phone number
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Details of the person completing the record.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The organisational role of the person completing record.
Valueset:
FHIR value set :- SDSjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
NHS data dictionary :- Professional registration identifier
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Contact details of the person completing the record.
Valueset:
NHS data dictionary : - UK telephone number
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Details of other risks, factors or behaviours relating to the person.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The location where the other risks were identified.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The coded value for location
Valueset:
NHS data dictionary : - Organisation data service
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The professional who identified the other risks.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
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:
Description:
Contact details of the professional
Valueset:
NHS data dictionary - UK phone number
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Details of the person completing the record.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The organisational role of the person completing record.
Valueset:
FHIR value set :- SDSjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
NHS data dictionary :- Professional registration identifier
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Contact details of the person completing the record.
Valueset:
NHS data dictionary : - UK telephone number
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Allergies and adverse reactions
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
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.
Each record entry is made up of a number of elements or data items.
Valueset:
-
Cardinality: 0 ... *
MRO: R
Information type:
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:
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:
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:
Description:
Details of the reaction.
Valueset:
-
Cardinality: 0 ... *
MRO: R
Information type:
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:
Description:
The coded value for location.
Valueset:
NHS data dictionary : - Organisation data service
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
Description:
A description of the severity of the reaction.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The coded value for severity
Valueset:
FHIR value set : - Severity
Cardinality: 0 ... 1
MRO: R
Information type:
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:
Description:
The coded value for certainty.
Valueset:
FHIR value set : - Certainty
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The route the person was exposed to the substance
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The professional who identified the reaction.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
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:
Description:
Contact details of the professional
Valueset:
NHS data dictionary - UK phone number
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Details of the person completing the record.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The organisational role of the person completing record.
Valueset:
FHIR value set :- SDSjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
NHS data dictionary :- Professional registration identifier
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Contact details of the person completing the record.
Valueset:
NHS data dictionary : - UK telephone number
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Medications and medical devices
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Each entry holds details of medications administered
Valueset:
-
Cardinality: 0 ... *
MRO: R
Information type:
Description:
May be generic name or brand name.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
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:
Description:
The route by which the medication is administered e.g. oral, IM, IV
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
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:
Description:
Medication item cluster
Valueset:
-
Cardinality: 0 ... *
MRO: R
Information type:
Description:
The location where the medication or the medical device was prescribed.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The coded value for location
Valueset:
NHS data dictionary : - Organisation data service
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The professional who prescribed the medication or medical device.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
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:
Description:
Contact details of the professional
Valueset:
NHS data dictionary - UK phone number
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
May be generic name or brand name.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
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:
Description:
The form of the medication e.g. capsule, drops, tablet, lotion etc.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The route by which the medication is administered e.g. oral, IM, IV
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The anatomical site at which the medication is to be administered.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
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:
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:
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:
Description:
Details of the overall course of medication.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The status of this prescription.
Valueset:
FHIR value set : - Medication status
Cardinality: 0 ... 1
MRO: R
Information type:
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:
Description:
Records the changes made to medication.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The nature of any change made to the medication.
Valueset:
FHIR value set : Medication status
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Details of the person completing the record.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The organisational role of the person completing record.
Valueset:
FHIR value set :- SDSjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
NHS data dictionary :- Professional registration identifier
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Contact details of the person completing the record.
Valueset:
NHS data dictionary : - UK telephone number
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Medical devices
Valueset:
-
Cardinality: 0 ... *
MRO: R
Information type:
Description:
Medication discontinued entry
Valueset:
-
Cardinality: 0 ... *
MRO: R
Information type:
Description:
The name of the medication or medical device being discontinued
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
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:
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:
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:
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:
Description:
The location where the care and support plan was prepared.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The coded value for location
Valueset:
NHS data dictionary: - Organisation data service
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The professional who prepared the care and support plan.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
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:
Description:
Contact details of the professional
Valueset:
NHS data dictionary - UK phone number
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Details of the person completing the record.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The organisational role of the person completing record.
Valueset:
FHIR value set :- SDSjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
NHS data dictionary :- Professional registration identifier
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Contact details of the person completing the record.
Valueset:
NHS data dictionary : - UK telephone number
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Contingency plans.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
Description:
The location where the advanced statement was made.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The coded value for location
Valueset:
NHS data dictionary: - Organisation data service
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Does the person have an advance statement.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The professional who made the advance statement.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
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:
Description:
Contact details of the professional
Valueset:
NHS data dictionary - UK phone number
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Details of the person completing the record.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The organisational role of the person completing record.
Valueset:
FHIR value set :- SDSjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
NHS data dictionary :- Professional registration identifier
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Contact details of the person completing the record.
Valueset:
NHS data dictionary : - UK telephone number
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Details of coping strategies used
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
Description:
The location where the contingency plan was prepared.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The coded value for location
Valueset:
NHS data dictionary : - Organisation data service
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The professional who prepared the contingency plans.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
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:
Description:
Contact details of the professional
Valueset:
NHS data dictionary - UK phone number
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Details of the person completing the record.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The organisational role of the person completing record.
Valueset:
FHIR value set :- SDSjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
NHS data dictionary :- Professional registration identifier
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Contact details of the person completing the record.
Valueset:
NHS data dictionary : - UK telephone number
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Additional support plans
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
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:
Description:
The location where the additional support plan was prepared.
Valueset:
ODS code or free text
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The coded value for location
Valueset:
NHS data dictionary:- Organisation data service
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The professional who prepared the additional support plan.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
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:
Description:
Contact details of the professional
Valueset:
NHS data dictionary - UK phone number
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Details of the person completing the record.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The organisational role of the person completing record.
Valueset:
FHIR value set :- SDSjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
NHS data dictionary :- Professional registration identifier
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Contact details of the person completing the record.
Valueset:
NHS data dictionary : - UK telephone number
Cardinality: 0 ... 1
MRO: R
Information type:
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.
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:
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:
Description:
The location where the cardio-pulmonary resuscitation decision was made.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The coded value for location
Valueset:
NHS data dictionary: - Organisation data service
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The cardio-pulmonary resuscitation (CPR) decision.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The professional who made the cardio-pulmonary resuscitation decision.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
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:
Description:
Contact details of the professional
Valueset:
NHS data dictionary - UK phone number
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Details of the person completing the record.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The organisational role of the person completing record.
Valueset:
FHIR value set :- SDSjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
NHS data dictionary :- Professional registration identifier
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Contact details of the person completing the record.
Valueset:
NHS data dictionary : - UK telephone number
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Details of the persons estimated prognosis
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The location where the estimated prognosis was made.
Valueset:
ODS code or free text
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The coded value for location
Valueset:
NHS data dictionary: - Organisation data service
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The professional who made the estimated prognosis.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
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:
Description:
Contact details of the professional
Valueset:
NHS data dictionary - UK phone number
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Details of the person completing the record.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The organisational role of the person completing record.
Valueset:
FHIR value set :- SDSjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
NHS data dictionary :- Professional registration identifier
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Contact details of the person completing the record.
Valueset:
NHS data dictionary : - UK telephone number
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Details of the persons awareness of prognosis
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
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:
Description:
The coded value for location
Valueset:
NHS data dictionary: - Organisation data service
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The professional who made the assessment of the level of awareness of the prognosis.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
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:
Description:
Contact details of the professional
Valueset:
NHS data dictionary - UK phone number
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Details of the person completing the record.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The organisational role of the person completing record.
Valueset:
FHIR value set :- SDSjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
NHS data dictionary :- Professional registration identifier
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Contact details of the person completing the record.
Valueset:
NHS data dictionary : - UK telephone number
Cardinality: 0 ... 1
MRO: R
Information type:
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:
Description:
Details of the person's anticipatory actions
Valueset:
-
Cardinality: 0 ... *
MRO: R
Information type:
Description:
The location where the anticipatory actions were identified.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The coded value for location
Valueset:
NHS data dictionary: - Organisation data service
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The professional who identified the anticipatory actions.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
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:
Description:
Contact details of the professional
Valueset:
NHS data dictionary - UK phone number
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Details of the person completing the record.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The organisational role of the person completing record.
Valueset:
FHIR value set :- SDSjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
NHS data dictionary :- Professional registration identifier
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Contact details of the person completing the record.
Valueset:
NHS data dictionary : - UK telephone number
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Details of the persons availability or location regarding their anticipatory medicines/equipment.
Valueset:
-
Cardinality: 0 ... *
MRO: R
Information type:
Description:
The location where the statement regarding anticipatory medicines/equipment was made.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The coded value for location
Valueset:
NHS data dictionary: - Organisation data service
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The professional who made the statement regarding anticipatory medicines/equipment was made.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
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:
Description:
Contact details of the professional
Valueset:
NHS data dictionary - UK phone number
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Details of the person completing the record.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The organisational role of the person completing record.
Valueset:
FHIR value set :- SDSjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
NHS data dictionary :- Professional registration identifier
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Contact details of the person completing the record.
Valueset:
NHS data dictionary : - UK telephone number
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Details of the person's preferred place of death
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The location where the preferred place of death was identified.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The coded value for location
Valueset:
NHS data dictionary: - Organisation data service
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The preferences that a person has identified as their preferred place to die.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
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:
Description:
The preferences that a person has identified as their preferred place to die.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
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:
Description:
The professional who identified the preferred place of death.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
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:
Description:
Contact details of the professional
Valueset:
NHS data dictionary - UK phone number
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Details of the person completing the record.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The organisational role of the person completing record.
Valueset:
FHIR value set :- SDSjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
NHS data dictionary :- Professional registration identifier
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Contact details of the person completing the record.
Valueset:
NHS data dictionary : - UK telephone number
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Details of the persons preferred place of care
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The location where the preferred place of care was identified.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The coded value for location
Valueset:
NHS data dictionary: - Organisation data service
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The professional who identified the preferred place of care.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
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:
Description:
Contact details of the professional
Valueset:
NHS data dictionary - UK phone number
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Details of the person completing the record.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The organisational role of the person completing record.
Valueset:
FHIR value set :- SDSjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
NHS data dictionary :- Professional registration identifier
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Contact details of the person completing the record.
Valueset:
NHS data dictionary : - UK telephone number
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Details about documents related to the person.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
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:
Description:
The professional who authored the document.
Valueset:
Free text.
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
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:
Description:
Contact details of the professional
Valueset:
NHS data dictionary - UK phone number
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The code specifying the level of confidentiality of the document.
Valueset:
FHIR value set : - Confidentiality
Cardinality: 0 ... 1
MRO: R
Information type:
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
Valueset:
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Details of the person completing the record.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The organisational role of the person completing record.
Valueset:
FHIR value set :- SDSjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
NHS data dictionary :- Professional registration identifier
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Contact details of the person completing the record.
Valueset:
NHS data dictionary : - UK telephone number
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Additional information required for images.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The procedure used to capture the image
Valueset:
Free text
Using DICOM code set https://dicom.innolitics.com/ciods
Using DICOM code set https://dicom.innolitics.com/ciods
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The professional who performed the image procedure.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
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:
Description:
Contact details of the professional
Valueset:
NHS data dictionary - UK phone number
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Details of the person completing the record.
Valueset:
-
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
The organisational role of the person completing record.
Valueset:
FHIR value set :- SDSjobrole
Cardinality: 0 ... 1
MRO: R
Information type:
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:
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:
NHS data dictionary :- Professional registration identifier
Cardinality: 0 ... 1
MRO: R
Information type:
Description:
Contact details of the person completing the record.
Valueset:
NHS data dictionary : - UK telephone number
Cardinality: 0 ... 1
MRO
Name
Description
R
Person’s usual place of residence, and where relevant temporary and correspondence addresses.
R
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
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
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
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
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
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
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
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
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.
R
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.
R
A record of reasonable adjustments that must be provided by the service to comply with the Equality Act 2010.
R
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
R
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.
R