Glossary

Glossary

On this page you will find a useful list of terms, commonly used in our line of work. Would you like to find out more or have a question for us? If so, please get in touch. 

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Electronic patient record  

An electronic patient record is the health (and care) record for a person using services. It is used in the care and support of a person by professionals or by the person themselves. The information held in an electronic patient record should be shareable across the system and accessible by professionals with a legitimate reason to access the information. A person may have more than one electronic patient record; for example, their GP and a hospital may have a record about them and the care and support they have received or need.

Shared care record 

A shared care record brings together health and care information about a person using services from multiple electronic records, held in different organisations, across an area. This means that the information about a person may come from the GP record, hospital records, local authority or care home systems, and is brought together in a record that is shared across the area with professionals with a legitimate reason to access the information.  

 

Person-held record 

A person-held record is the information about a person’s health, care and wellbeing. It is managed by the person who the record is about, and they can add to it. Health and care professionals can also add to the record. It must be secure, usable and online. Personal Health Records definition – NHS Digital 

Use case

A use case is an action (or series of actions) that an actor performs using a system. An actor is a role rather than an individual and can be human or an external system. For example, a GP (actor) records a patient’s blood pressure (action). 

 
SNOMED CT 

Systematised Nomenclature of Medicine Clinical Terms (SNOMED CT) is a structured clinical vocabulary for use in an electronic patient record. It gives clinical systems a single shared language, which makes exchanging information between systems easier, safer and more accurate. It contains the clinical terms needed for the NHS, from procedures and symptoms through to clinical measurements, diagnoses and medications. The UK edition of SNOMED CT also contains UK extensions. These provide terms specifically required in the UK, such as UK screening procedures and assessment scales. 

 

dm+d 

The Dictionary of Medicines and Devices (dm+d) is a dictionary of descriptions and codes which represent medicines and devices in use across the NHS. It is a standard that enables information about medicines and devices to be shared between clinical systems. It includes information such as the indicative price of each pack of a product and current and discontinued products and packs available from manufacturers and suppliers. Dictionary of  ) | NHSBSA 

 

NHS Data Model and Dictionary 

This is the reference for nationally assured information standards to support health care activities in the NHS in England. It sets out the valid codes or content for recording information in attributes of each data set. About the NHS Data Model and Dictionary (datadictionary.nhs.uk) 

 

ODS 

The Organisation Data Service (ODS) manage identification codes and reference data for organisations that interact with any area of the NHS. ODS codes are needed for NHSmail accounts and sending referral information. NHS Digital ODS Portal 

 

UCUM 

The Unified Code for Units of Measure (UCUM) is a code system intended to include all units of measures used in international science, engineering and business. It enables information about quantities and their units to be shared between systems. UCUM 

 
FHIR 

Fast Healthcare Interoperability Resources (FHIR) is the global industry standard for sharing healthcare data between systems. FHIR are part of an international family of standards developed by Health Level-7 UK (HL7). The information models and APIs developed using this standard provide a means of sharing health and care information between providers and their systems, no matter the setting in which care is delivered. FHIR (Fast Healthcare Interoperability Resources) – NHS Digital

CHAT theory also explicitly addresses five areas which if addressed systematically will help overcome stakeholder differences in pursuit of the common goal:

1. Understanding the artefacts that characterise the group and its activity.
• The artefacts might be clinical settings or the forms and templates used to capture and share information. During the pilot we heard about hard copy Dialog response forms; locally generated templates for collating information from different systems; letters and emails to GPs; images, poems or other non-text artefacts that service users might want to include in their ‘about me’ or care plan.

2. Understanding the multi-views of the group. Such groups are always a community of multiple points of view, traditions and interests. 
• Different participants in the group will have different roles and will bring to the group and their roles their own histories, language, and ‘rules’. During our Stocktake preparations and workshops we worked with psychiatrists, mental health nurses, occupational therapists, social workers, transformation leads and voluntary sector representatives, all professions and interests with their own language, approaches professional ‘rules’ but united in their interest in care plans, care planning.

3. Activity systems (like the ICSs) take shape and get transformed over periods of time. ‘Historicity’ is a term coined to express how the group’s problems and potentials can only be understood against their own history. 

 

• ‘We’ve always done it this way’, ‘that didn’t work before’, ‘it’s always like this’, ‘it wasn’t always like this’, ‘they are changing things again’, are all typical statements that often frustrate those charged with overseeing change initiatives. Without addressing the experiences that lie behind such comments you risk repeating mistakes of the past, alienating your stakeholders or just not understanding the real starting point for your transformation project. This is particularly the case for the implementation of the PCSP standard, the success of which will be largely reliant on point-of-care practices and information protocols as well as having systems which are user friendly and appropriately configured.

4. The central role of contradictions as sources of change and development. Contradictions are not the same as problems or conflicts. Contradictions are historically accumulating structural tensions within and between activity systems. Collectively addressing contradictions in how policy, practice, culture and technology interact will empower teams to find genuinely novel solutions for apparently intractable challenges, like interoperability and shared care plan/planning. 

This links to the fifth principle that:

5. the possibility of expansive transformations in activity systems. As the contradictions of an activity system are aggravated, some individual participants begin to question and deviate from its established norms. In some cases, this escalates into collaborative envisioning and a deliberate collective change effort. “An expansive transformation is accomplished when the object and motive of the activity are re-conceptualised to embrace a radically wider horizon of possibilities than in the previous mode of the activity.”