Shared Decision Making Standard
Shared decision making is a collaborative process where clinicians and individuals consider treatment options based on evidence about their potential benefits and harms, to enable the person to decide the best course for themselves. The conversation and decision made should be informed by what matters to the person, their goals, values, hopes, ideas, concerns and expectations.
When people are listened to, given the information they need and the time and support to make informed decisions about their care and treatment, they have the potential for better outcomes and experiences of care.
Current release
Version: V1.0 | |||
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Release date | January 2025 | ||
Release notes |  | ||
Next release date | January 2028 | ||
Next release type | Standard 3 year review | ||
The standard | |
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Full standard – PRSB viewer | 
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Full standard – Excel |  |
Full standard – Json |  |
Supporting documentation | Description/purpose |
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ISN status: DAB initial approval given to proceed (DAPB4070) | For England the Data Assurance Board has delegated authority from the secretary of state for health to approve and mandate standards including under section 250 of the Health and Social Care Act 2012.
For Wales the Welsh Information Standards Board approves information standards. |
Implementation guidance | This document includes general implementation guidance for all PRSB standards. Detailed implementation guidance specific to the sections and elements of this standard are included within the information model. |
| Rules for implementation of the standard. |
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| Describes the purpose, methodolgy and stakeholder engagement for developing the standard, along with the findings and recommendations for further work. |
| Summarises the hazards which could result from implementing the standard. |
| Details the potential hazards from implementing the standard with their risk rating and mitigation. |
Provenance data | Defines the information on who made a record entry and who carried out the activity, where and when. |
Need implementation support?
- Online support form
- Support@theprsb.org
- 020 4551 5225 (9-5 Mon-Fri, excl. bank holidays)
About this standard
The PRSB information standard on shared decision making provides a framework for clinicians to record the decision-making process between themselves and their patients. The standard also allows the shared decision information to be shared between professionals and their different record systems. The standard has been developed based on the GMC guidance on shared decision-making and consent and the NICE guidelines.
Scope
- The standard was developed with UK wide consultation and engagement to meet the needs of all four UK nations.
- The standard is intended for all areas of healthcare except for the noted exclusions
- The standard covers all ages including children
The following 8 different scenarios were used to help develop and test the standard;
- Elective surgery
- Multiple long-term conditions
- Mental Health
- Genetic conditions
- Polypharmacy
- Orthopaedics
- Gynaecology
- Children and dentistry
Not in scope:
- Maternity – The standard may work for maternity, but it is believed that this complex area justifies specific additional work and potentially an extended standard.
- Social Care – The Shared Decision Making Standard is defined for clinical uses and the consultation was targeted at healthcare professionals not social care professionals. However the standard’s principles may work in social care and in the future the standard could potentially be adapted for use in social care.
How it works
The standard sets out the information that should be recorded for a shared decision making discussion between a clinician and patient, and then shared afterwards with the patient and other professionals who care for them.
Here is an excerpt from a summary view of the standard that shows main sections and elements. It gives a description of the information to be captured and also tells the clinician what information is Mandatory (M – must be recorded), Required (R – should be recorded if the information exists), and what is Optional (O – local decision if its recorded) in the Conformance column.
Section and element name | Conformance | Description |
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Problem list | M | A summary of the problems that require investigation or treatment. |
Problem | M | The problem that the shared decision is addressing |
Shared decision point
| M | This is a shared decision point record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items. |
Shared decision status | M | The current status of the decision (In progress, Valid, Cancelled). |
Pre-discussion information shared
| R | A record of the actions taken to prepare the patient to make a shared decision before the encounter where a shared decision was made. This should include a summary of any resources the person was offered to prepare them for the decision making process.
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This is an excerpt taken from a high-level summary view of the standard. Open the full summary table below.
| Section and element name | Conformance | Description |
| Contacts with professionals | The details of the person’s contact with a professional. Repeated for each contact (appointment/meeting) | |
| Date, location, who seen by, responsible professional | M | |
| Method (e.g. face to face), Use of interpreter | R | |
| Recording indicator and consent for recording | R | |
| Other professionals present and people accompanying the person | R | |
| Problem list | M | A summary of the problems that require investigation or treatment. |
| Problem | M | The problem that the shared decision is addressing |
| Shared decision point | M | This is a shared decision point record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items. |
| Shared decision status | M | The current status of the decision (In progress, Valid, Cancelled). |
| Pre-discussion information shared | O | A record of the actions taken to prepare the patient to make a shared decision before the encounter where a shared decision was made. This should include a summary of any resources the person was offered to prepare them for the decision making process. |
| Discussion actions | R | A record of the actions taken to support shared decision making during the encounter. |
| People involved in making the decision | R | This section records all those who were involved in the shared decision, either with the person or on behalf of the person. This may be where the person does not have mental capacity or the decision is made in the person’s best interest as a shared decision. People involved in the decision may include family members, carers, Legal Power of Attorney, Independent Mental Capacity Advocate. |
| Agenda setting | O | A record of the agenda setting process undertaken to support the shared decision covering both the patient and clinician agendas. |
| What matters to the person | M | A record to establish what matters to the person in the context of the decision to be made, which may include as appropriate: Person goals, values, hopes, ideas, concerns, expectations. |
| Options, risks & benefits discussed | M | Record of the options discussed with risks and benefits. Where relevant the option to ‘take no further action’ at this time or to ‘do nothing’ should be included in the options discussed. |
| Decision support tools | R | Record of any decision support tools used. |
| Recording the decision | M | Details of the decision made with person. This includes details of the decisions made and agreed timescales for review. |
| Decision Issues | R | A flag to indicate whether the patient held issues, reservations or comments with the decision agreed, or if the clinician had any comments about the decision. If Yes, then issues or comments should be recorded |
| Information withheld or sharing delayed | R | A record of any information that is withheld or the sharing is delayed, with reasons. This may occur in very exceptional circumstances |
| Post-discussion actions | O | A record of the actions agreed to support the shared decision after the appointment for both the professional and the person or their carer. |
| Consent form details | O | Record of type of consent form used and where it is located |
Conformance Definitions
Mandatory (M) – the information must be included/recorded
Required (R) – if it exists, the information should be included/recorded
Optional (O) – local choice if the information is included/recorded
Below we can see an example of a shared decision making journey from starting a shared decision with a patient and their clinician, through to planning and discussion and then making a final agreement to document in a patient’s care record. This journey will often be over multiple appointments and could be with different clinicians. The standard is designed for this and also to allow for pauses in the process for consideration and reflection and for changes of the decision.
Starting a shared decision
The first meeting | Joe meets or talks on the phone with his clinician (this is his doctor or nurse or other health professional) who has diagnosed the problem.
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The clinician explains the diagnosis to Joe and says there are choices for his treatment or support.
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The clinician gives Joe some information on the choices available to consider before further meetings. |
The clinician asks if Joe would want someone to be at the next meeting.
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Shared decision discussions
Talking through the choices | Joe meets the clinician to discuss the best treatment or support for him. This is the shared decision making discussion.
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Joe consents to the meeting being recorded so it can be referred to later.
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The clinician checks with Joe to agree that this is the expectation for the meeting so that he understands his diagnosis. |
The clinician and Joe explore what’s important to Joe, his concerns, expectations, needs and goals.
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The clinician explains each of the options along with their risks and benefits for Joe.
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They discuss and reach a shared decision on the best option for Joe. Joe decides he needs more time to consider. The doctor sends Joe a letter with the details of the discussion.
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Reaching a final decision
Agreeing what is important | They recap and discuss as needed, considering what’s important to Joe, the options and their risks and benefits.
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They record the option agreed and a review date. If needed they can record any issues Joe had with the decision or any comments made by the clinician.
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If required, Joe provides consent for the chosen treatment or support. Details about the consent form are recorded. |
The clinician notes the actions for Joe and themselves (such as to start the chosen treatment or support option).
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Examples
To give a clearer idea of how the standard works in practice we have created some examples to help make it clearer what information is recorded in different SDM scenarios, and how this works across multiple appointments.
These examples are based on role plays with practising clinicians and either patients or actors. In some cases they are shown with two views, one for clinicians and people and another for system suppliers using the full information model.
Further resources
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- Standards explained
PRSB’s guide to standards which sets out the purpose and benefits of using standards and how to support frontline professionals to adopt them. - Managing incorrect information in health records – IHRIM Good Practice Guidance
Despite vigilance when filing information in records, mistakes can occur. The Institute of Health Records and Information Management has guidance to support professionals in making corrections following errors.
Endorsement
This standard has been endorsed by the following organisations:
- Royal College of Anaesthetists
- Royal College of General Practitioners
- Royal College of Occupational Therapists
- Royal College of Psychiatrists
- Royal College of Radiologists
- Royal College of Surgeons
- Royal Pharmaceutical Society
- British Orthodontics Society
- British Psychological Society
- Centre for Perioperative Care
- Patient Information Forum
This standard is dedicated to the memory of Mr James Brown, clinical lead on the standard development.