v2.2-Frozen before metadata changes, incremented to v2.21
v2.3 frozen before changes made and incremented to v2.4
V2.4 frozen following feedback from project board and assurance committee.
V2.5 frozen after adding the assessments section.
V3.0 frozen after making amendments to implementation guidance of NEWS 2 score and blood pressure.
V3.0.1 frozen after updating blank operationalisation fields.
V3.01 Frozen after updating implementation guidance for 'Reason for service', and reformatting version structure.
V3.01.03 Updated clinical narrative implementation guidance to specify that this field also covers 'Professional discussions undertaken'. Update consultation outcome implementation guidance to include more valueset options for different CPCF services.
", "concept": [{"type": "group", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "M", "name": "Person demographics", "implamentationGuidance": "The mandatory information in this section is person\u2019s name, date of birth, sex, and address. On the address, not all the fields have been made mandatory except for the 1st line of address, to allow the input of just enough of a person\u2019s address.
", "description": "The person's details and contact information.", "informationType": "Record", "concept": [{"type": "group", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "M", "name": "Person name", "description": "Details of the person's name", "concept": [{"type": "item", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "M", "name": "Person first name", "description": "The first name(s) of the person. This includes middle names.", "valueSets": "NHS data dictionary :- Person given name \n ", "valueDomain": [{"type": "string", "property": [{"maxLength": "35"}]}]}, {"type": "item", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "M", "name": "Person family name", "description": "The family name or surname of the person", "valueSets": "NHS data dictionary : - Person family name \nThe definitions used for sex and gender use the NHS data dictionary definitions to ensure interoperability with other systems. However, we recognise that the definitions used do not reflect today\u2019s more inclusive society. We have provided feedback on this to NHS data dictionary team in NHS Digital who are actively addressing this area, and\n any updates to the NHS data dictionary will update our standards.
Sex and gender data items may cause accidental disclosure of gender reassignment without consent. This is because both fields are included in the demographic model. Having both may show a difference and therefore disclose gender reassignment without consent. It is unlawful to disclose,\n without consent, a person\u2019s gender reassignment with or without a gender reassignment certificate.
Section 22 of the Gender Recognition Act 2004 makes it an offence to disclose the history of a transgender patient who has had formal gender reassignment under the Act, unless consent has been sought. The exemption of disclosure is for medical professionals\n involved in direct medical care, but not currently for administrative and non-medical staff. For the full Act, see https://www.legislation.gov.uk/ukpga/2004/7/contents.
This risk can be mitigated by appropriate implementation of the record; refer to the\n Community Pharmacy Standard clinical safety case report and hazard log. One option is to leave out the \u201cSex\u201d field but the implications and potential risks of that will need to be considered. The alternative is to ensure the design of the record, including its Information Governance model, reduces this risk to an acceptable level as described in the clinical\n safety case and hazard log. A further mitigation on implementation could be to record self-expressed gender in the administrative area of systems, and record sex at birth in a separate clinical area, that can only be accessed by medical staff.
", "description": "The person's stated gender.", "valueSets": "NHS data dictionary :- Person stated gender code \nThe definitions used for sex and gender use the NHS data dictionary definitions to ensure interoperability with other systems. However, we recognise that the definitions used do not reflect today\u2019s more inclusive society. We have provided feedback on this to NHS data dictionary team in NHS Digital who are actively addressing this area, and\n any updates to the NHS data dictionary will update our standards.
Sex and gender data items may cause accidental disclosure of gender reassignment without consent. This is because both fields are included in the demographic model. Having both may show a difference and therefore disclose gender reassignment without consent. It is unlawful to disclose,\n without consent, a person\u2019s gender reassignment with or without a gender reassignment certificate.
Section 22 of the Gender Recognition Act 2004 makes it an offence to disclose the history of a transgender patient who has had formal gender reassignment under the Act, unless consent has been sought. The exemption of disclosure is for medical professionals\n involved in direct medical care, but not currently for administrative and non-medical staff. For the full Act, see https://www.legislation.gov.uk/ukpga/2004/7/contents.
This risk can be mitigated by appropriate implementation of the record; refer to the\n Community Pharmacy Standard clinical safety case report and hazard log. One option is to leave out the \u201cSex\u201d field but the implications and potential risks of that will need to be considered. The alternative is to ensure the design of the record, including its Information Governance model, reduces this risk to an acceptable level as described in the clinical\n safety case and hazard log. A further mitigation on implementation could be to record self-expressed gender in the administrative area of systems, and record sex at birth in a separate clinical area, that can only be accessed by medical staff.
", "description": "The person\u2019s phenotypic sex. Determines how the person will be treated clinically.", "valueSets": "NHS data dictionary: - person phenotypic sex \n ", "valueDomain": [{"type": "string", "property": [{"maxLength": "1"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "NHS number", "implamentationGuidance": "In England, Spine-compliant systems are needed to obtain traced NHS numbers. Pharmacy systems are spine-enabled for the electronic prescription service (EPS) so should always know the patient\u2019s NHS number and hence GP practice. Where an organisation does not have a system linked to the Personal Demographics Service (PDS), other demographics\n fields will need to be used, with local person identity matching software.
Pharmacists record patient demographics for their own records, but they only need to communicate to the GP practice the data items needed for record matching (i.e., NHS number and one other searchable item such as date of birth). NHS Number should only be used if NHS Number Status\n Indicator Code has value \u201801\u2019 (i.e., it has been verified against the Personal Demographics Service. Status Indicator Code values other than \u201801\u2019 should still be sent with the NHS number status indicator code (datadictionary.nhs.uk/data_elements/nhs_number_status_indicator_code.html). NHS number (or equivalent, e.g., CHI number in Scotland) is required, but with the option to record \u2018Not Known\u2019 or \u2018Not Available\u2019. Existing national guidance should be followed, including how to handle patients without an NHS number, e.g., overseas visitors, service personnel,\n prisoners.
", "description": "The unique identifier for a person within the NHS in England and Wales.", "valueSets": "NHS data dictionary:- NHS number \n ", "valueDomain": [{"type": "string", "property": [{"maxLength": "10"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Other identifier", "implamentationGuidance": "The \u2018other identifier\u2019 heading may also be used to record the pharmacy case number.
", "description": "Country specific or local identifier, e.g. Community Health Index (CHI) in Scotland.", "valueSets": "\nAlthough this field is Mandatory in the majority of cases, an option should be included to omit completing this field in the case that a protected patient has access restricted to their data where they may be at risk. The process is often referred to as \u201cs-flagging\u201d, so an EPS prescription would be received without patient address\n information.
", "description": "Person's first line of address.", "valueSets": "\nDetails of the person's GP practice.
\n ", "concept": [{"type": "group", "minimumMultiplicity": "1", "maximumMultiplicity": "*", "mro": "M", "name": "GP practice record entry", "description": "This is an GP practice record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items", "informationType": "Record", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "GP name", "implamentationGuidance": "Many people will not offer a named GP. Only the \u2018GP practice details\u2019 heading would need to be completed in these situations.
", "description": "The name of the person's GP. If the person is registered with a GP practice, their usual GP name will be something volunteered by the person or their representative.", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "70"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "GP practice details", "implamentationGuidance": "GP Practice Name should be displayed unambiguously to the pharmacist for lookup and selection. It is intended to be used to provide the GP practice details via lookup from national registers. These details would be obtained by the PDS or via a look up file of Organisation Data Service (ODS) codes provided by NHS Digital.
", "description": "Name and address of the person's registered GP Practice. Registered GP practice details are available from the Person Demographics Service (PDS), or volunteered from the person or their representative. Include details of the practice name and address.
", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}, {"type": "item", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "M", "name": "GP practice identifier", "implamentationGuidance": "\u2018GP practice identifier\u2019 does not need to be a displayed field.
", "description": "The identifier of the registered GP practice.", "valueSets": "\nA record of consent for service, consent relating to children and consent for information sharing should be captured in the clinical system. Please note these headings are included in a separate \u2018consent\u2019 section for this standard to reflect the way pharmacists work.
", "description": "The legal information relating to the person.", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Consent for treatment record", "description": "Details of the person's consent for treatment.", "informationType": "Event.Record", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Consent for treatment record", "description": "Whether consent has been obtained for the treatment. May include where record of consent is located or record of consent. A statement about the patient's consent for treatment.", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Location of document", "description": "The location of the consent for treatment record.", "valueSets": "Free text or URL", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Consent for information sharing", "description": "\nThis section includes any concerns in relation to safeguarding and is applicable to children and adults. This section includes whether a child is looked after and indicates the presence of a Child Protection Plan or Unborn Child Protection Plan.
There may be situations where it is not advisable to share information in this section\n with the person to whom it relates, so local implementations may need to apply filters in these cases. Appropriate policies and technical solutions need to be in place for these situations.
Access must be controlled to this information as per SCCI1609: Child Protection - Information Sharing.
", "description": "The safeguarding details of the person.", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Safeguarding concerns", "description": "\n1010196001 |Safeguarding concern (finding)| and 861931000000100 |No safeguarding issues identified (finding)|
", "description": "Indicates whether or not the hospital considers that there are safeguarding issues associated with the patient.", "valueSets": "Flag: No =N: Yes = Y", "valueDomain": [{"type": "boolean"}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Safeguarding concerns", "description": "Identified safeguarding concerns.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for safeguarding concerns", "valueSets": "SNOMED CT : - ^999002381000000108 | Safeguarding issues simple reference set (foundation\n metadata concept) | \n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Comment", "description": "Further details on safeguarding concerns.", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Referral details", "implamentationGuidance": "This section includes a record of current and historic referrals. Referral details includes the service a person is being referred from. Therefore, this section should be used to capture information for both referrals into and out of the pharmacy.
", "description": "The details of the referral.", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Referral details record entry", "description": "This is the referral details record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.", "informationType": "Event.Record", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date", "description": "The date of referral", "valueSets": "Date and time", "valueDomain": [{"type": "datetime", "property": [{"timeStampPrecision": "YMDHM"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Referrer details", "implamentationGuidance": "Referrer details (e.g., NHS111, healthcare professional referral) should be copied forward from the referral or transfer of care where possible.
Coded text \u2018self-referral\u2019 should be used where the patient is not referred or transferred from a health/care organisation. Where \u2018self-referral\u2019 is recorded the referrer data items should be\n left blank. This section is about who referred the patient to the pharmacy service whereas the \u2018referral details\u2019 section is to provide information to the GP about any referrals made.
", "description": "The details of the referrer that is making the referral or the transfer.A service may not always be coded. If the service is known, and a code is available, it should be included otherwise the service should be described in free text.
", "description": "The coded value for service", "valueSets": "SNOMED CT: -\u00a01127531000000102 |Services simple reference set (foundation metadata concept)|"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The organisation of the referrer.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for organisation code", "valueSets": "NHS data dictionary : - Organisation data service
", "valueDomain": [{"type": "string", "property": [{"minLength": "3", "maxLength": "5"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Referral type", "implamentationGuidance": "This data item can be used to capture the referrer organisation type.
", "description": "An indication of the type of referral (e.g. 'Hospital Discharge Notification to Social Care', 'GP Referral', etc.)", "valueSets": "Free text
", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "The contact details of the referrer.", "valueSets": "Free text", "valueDomain": [{"type": "string", "property": [{"maxLength": "70"}]}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Person Referral Reference", "description": "A human-readable reference given to the person to use when contacting or going to the service referred on to. It is generated by the receiving service and supplied to the referrer as part of the Booking and Referral Standard (BaRS) messaging.
Free text
", "valueDomain": [{"type": "string"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Journey ID", "description": "This is a machine-readable reference which the Sender of any initial referral (i.e. it was not sent to them as a referral) generates and includes in their referral request. If the sender is not the initial referrer (i.e. they received a referral) they must include the original reference in their referral.\n
", "valueSets": "This should be a globally unique identifier (GUID) value. https://learn.microsoft.com/en-us/windows/win32/api/guiddef/ns-guiddef-guid\u00a0
", "valueDomain": [{"type": "string"}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Reason for referral", "description": "The reason for the referral, e.g. diagnosis, treatment, transfer of care due to relocation, investigation, second opinion, management of the patient (e.g. palliative care), or carer's concerns.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for reason for referral", "valueSets": "This section includes the details of the person\u2019s contacts with services, their encounters. This information may need to be filtered to only display what is relevant for a particular use case and professional\u2019s discipline.
", "description": "The details of the person\u2019s contact with a professional.", "concept": [{"type": "group", "minimumMultiplicity": "1", "maximumMultiplicity": "*", "mro": "M", "name": "Contacts with professionals record entry", "description": "This is a contacts record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.", "informationType": "Event.Record", "concept": [{"type": "item", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "M", "name": "Date and time of contact", "description": "Date and time of the contact.", "valueSets": "Date and time.", "valueDomain": [{"type": "datetime", "property": [{"timeStampPrecision": "YMDHM"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Location of contact", "description": "The location where the contact took place.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for location", "valueSets": "NHS data dictionary : - Organisation data service code \nThe reason for service should drive the information that will be captured by the pharmacy and sent to the GP record as shown in the data matrix in the implementation guidance. The valueset for this data item should be guided by community pharmacy services. At this time, the current list of services provided by community pharmacies is\n included below.
New Medicine Service
Appliance Use Review Service
Vaccination Administration Service
Community Pharmacist Consultation Service (Emergency Supply)
Community Pharmacist Consultation Service (Minor Illness)
Smoking Cessation Service
Blood Pressure\n Check Service
Pharmacy Contraception Service
Hepatitis C Testing Service
Discharge Medicine Service
Data item to be populated by system with \"Community Pharmacy\".
", "description": "Type of contact e.g. GP consultation, outpatient attendance", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Consultation method", "description": "Consultation method used e.g. face to face, telephone", "valueSets": "NHS data dictionary - Consultation mechanism \n ", "valueDomain": [{"type": "string", "property": [{"maxLength": "2"}]}]}, {"type": "group", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "M", "name": "Service", "description": "The service that was provided
", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded Value", "description": "The code for service provided
", "valueSets": "SNOMED CT :- ^1127531000000102 |Services simple reference set (foundation metadata concept)|
", "valueDomain": [{"type": "string"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "description": "Free text to be used if no code is available
", "valueSets": "Free text
"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Outcome of contact", "implamentationGuidance": "Use NHS data dictionary if the service specification requires outcome of contact for secondary use data only. Otherwise use the following SNOMED CT: 3780001 |Routine patient disposition, no follow-up planned (procedure)| AND 896511000000107 |Follow-up appointment offered (situation)| AND 183616001 |Follow-up arranged (finding)|\".
Some\n services have specific outcomes which should be included in the valueset when the clinician is carrying out that service:
New Medicine Service
\"No action needed\"
\"Pharmacist and patient agree solution\"
\"Referral to GP practice for review\"
\"Referral to other prescribing\n organisation\"
\"Patient requires/requests Additional Follow up\"
Contraception
\"Supply Made\"
\"Supply Made & Referred/Signposted\"
\"No Supply - Clinically inappropriate & Referred/Signposted\"
\"No Supply - Declined by Patient\"
\"No supply\n - Escalated\"
\"No Supply - Other reason (please state)\"
Discharge Medicine Service
\"Advice provided on medicines regimen and\u00a0questions answered\"
\"Onward referral\"
\"Other CPCF service provided\"
Community Pharmacist Consultation\n Service
\"Advice given only\"
\"Sale of an Over the Counter (OTC) medicine\"
\"Referral into a pharmacy local minor ailments service (MAS)\"
\"Referral into an appropriate locally commissioned NHS service, such as a patient group direction\"
\"Medicines supply /\n non-supply\"
\"Onward referral to another CPCS pharmacy
\"Non-urgent signposting to another service\"
\"Urgent escalation to another service\"
\"Other (please state)\"
Record of medication should be captured, even when there is no supply.
", "description": "The reason why the patient was not provided with the service e.g. declined, did not attend etc.", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Reason for service discontinuation", "description": "The reason why the patient discontinued the service e.g. declined, did not attend etc.\u00a0
", "valueSets": "Free text
", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}, {"type": "item", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "M", "name": "Clinician name", "description": "The name of the person providing the service.", "valueSets": "Free text", "valueDomain": [{"type": "string", "property": [{"maxLength": "70"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The role of the person providing the service.", "valueSets": "FHIR values set : -\u00a0 ukcorepractitionerrolecode \n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Chaperone", "description": "The name of any chaperone(s).", "valueSets": "Free text", "valueDomain": [{"type": "string", "property": [{"maxLength": "70"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person collecting the medicine", "description": "\nProfessional identifier for the professional providing the service e.g. General Medical Council (GMC), Nursing Medical Council (NMC) number etc, or the personal identifier used by the local organisation.
", "valueSets": "Free text
", "valueDomain": [{"type": "string", "property": [{"maxLength": "32"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier type", "implamentationGuidance": "PRSB suggest users use generic professional identifier types to suit the customer base where applicable, which should align with nationally identified professional identifier types that are coded (or will be in future).
Professional identifier types may be customised by users. Where no alignment is available to standardised lists,\n users may add to the list of professional identifier types.
NHS Data Dictionary 'Professional Registration Body Code':
https://www.datadictionary.nhs.uk/attributes/professional_registration_body_code.html
", "description": "\nThe type of professional identifier. For example, General Medical Council (GMC); Nursing and Midwifery Council\u00a0(NMC) numbers.
\n ", "valueSets": "\nNationally or internationally maintained code system(s) (see implementation guidance).
\n "}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Admission details", "description": "Admission details", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Admission details record entry", "implamentationGuidance": "This record entry is used for the smoking cessation service to record the reason for admission. This information will be shared with the pharmacy by the referring NHS trust.
", "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.", "informationType": "Event.Record", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date of admission", "description": "Date and time the person was admitted to hospital.", "valueSets": "Date and time", "valueDomain": [{"type": "datetime", "property": [{"timeStampPrecision": "YMDHM"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Reason for admission", "description": "The health problems and issues experienced by the person that prompted the decision to admit to hospital e.g. chest pain, mental health crisis, blackout, fall, a specific procedure, intervention, investigation or treatment, non compliance with treatment.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for reason for admission", "valueSets": ""}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Discharge details", "description": "Discharge details", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Discharge details record entry", "description": "This is the discharge details record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.", "informationType": "Event.Record", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date of discharge", "description": "The date and time of discharge", "valueSets": "Date and time", "valueDomain": [{"type": "datetime", "property": [{"timeStampPrecision": "YMDHM"}]}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Future appointments", "description": "Details of future appointments.", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Future appointments record entry", "description": "This is the future appointments record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.", "informationType": "Record", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date of appointment", "description": "Date and time of future appointment.", "valueSets": "Date and time", "valueDomain": [{"type": "datetime", "property": [{"timeStampPrecision": "YMD"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Appointment status", "description": "The status of the appointment e.g. proposed, booked, confirmed, rejected.", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Reason for appointment", "description": "Reason this appointment is scheduled e.g. diagnosis, investigation, treatment or assessment", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Clinical urgency of appointment", "description": "Urgency of appointment.", "valueSets": "NHS data dictionary : - Priority \n ", "valueDomain": [{"type": "string", "property": [{"maxLength": "1"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Location of future appointment", "description": "The location of the appointment.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for location", "valueSets": "\nIn future, vaccination information will be captured by scanning the GS1 barcode of the vaccine. Additional information on GS1 is available at https://www.gs1uk.org/standards-services/standards. GPs record vaccinations as procedures, thus it\n will be important for pharmacists to also record vaccinations as procedures in SNOMED CT, as well as recording the actual product using dm+d.This is important so that a flu vaccination can be recorded as both a clinical intervention and the supply of a medicinal product. For inclusion in GP records, the message needs to indicate that it contains vaccination\n procedures that if configured by the receiving system could be either: \u00b7
automatically entered into the receiving system without user intervention\u00b7
added to workflow for clinician review to enable a clinical decision as to whether or not to enter the information into the record.
\n
This is the vaccinations record entry.
\n\n
There may be 0 to many record entries under a section.
\n\n
Each record entry is made up of a number of elements or data items.
\n ", "informationType": "Event.Record", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date", "description": "The date on which the vaccination was administered or the reported/partial date on which it was reported.", "valueSets": "Date and time", "valueDomain": [{"type": "datetime", "property": [{"timeStampPrecision": "YMDHM"}]}]}, {"type": "group", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "M", "name": "Vaccine product", "description": "The vaccine product administered.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implamentationGuidance": "^553391000001108 |National Health Service dictionary of medicines and devices vaccine products simple reference set (foundation metadata concept)|
", "description": "The coded value for vaccine product.", "valueSets": "dm+d (SNOMED) Concept ID AMP (preferred) or VMP term for the vaccine productUse DM+D or GS1.
", "description": "The coded value of the manufacturer.", "valueSets": "SNOMED CT: - DM+D or GS1"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "group", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "M", "name": "Vaccine procedure", "description": "The procedure which was used to administer the vaccine.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The batch number of the vaccination will be recorded in the pharmacy PMR system, but not shared with the patients GP.
", "description": "The batch number of the product.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for the batch number", "valueSets": "FMD code : - Derived from Falsified medicines directive"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Expiry date", "implamentationGuidance": "The expiry date of the vaccination will be recorded in the pharmacy PMR system, but not shared with the patients GP.
", "description": "The date on which the vaccine will expire.", "valueSets": "Date/time", "valueDomain": [{"type": "datetime", "property": [{"timeStampPrecision": "YMDHM"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Serialisation code", "description": "A code that separately identifies two identical vaccines (i.e. same product, same batch).", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for serialisation code.", "valueSets": "FMD code : - Derived from Falsified medicines directive"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Body site", "description": "Body site vaccine was administered.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for body site", "valueSets": "Free text
", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Route", "description": "How the vaccine entered the body.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for vaccination route", "valueSets": "Free text
", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Indication", "description": "The clinical indication or reason for administering the vaccine.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for Indication.", "valueSets": "Free text
", "valueDomain": [{"type": "string"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Manufacturer", "description": "Name of appliance manufacturer", "valueSets": "Free text", "valueDomain": [{"type": "string"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Batch number", "description": "The batch number of the appliance.", "valueSets": "Free text", "valueDomain": [{"type": "string"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Size", "description": "The size of the appliance.", "valueSets": "UCUM", "valueDomain": [{"type": "quantity"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Weight", "description": "The weight of the appliance.", "valueSets": "UCUM", "valueDomain": [{"type": "quantity"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Colour", "description": "The colour of the appliance", "valueSets": "Free text", "valueDomain": [{"type": "string"}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Route", "description": "Appliance administration description (IM, IV, etc.): may include method of administration, (e.g., by infusion).", "valueSets": "\n SNOMED CT: -\u00a0 \n ^999000051000001100 |ePrescribing route of administration simple reference set (foundation metadata concept)| \n ", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded Value", "description": "Coded value for appliance route", "valueSets": "\n \nFree text
", "valueDomain": [{"type": "text"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Site", "description": "The anatomical site at which the appliance is to be used, including laterality.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded Value", "description": "Coded value for site", "valueSets": "\n \nFor referrals from NHS 111 to a CPCS attendance, the \u2018reason for referral\u2019 may include a diagnosis code and a symptom code.
", "description": "Presenting complaints or issues", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Presenting complaint or issue", "implamentationGuidance": "This element is to be completed by the pharmacist, rather than populated by inbound information. This element may repeat the chief complaint, or list other presenting complaints/issues. The information in this element may present more up to date information than the chief complaint, following consultation with the pharmacist to reflect the\n outcome of their impressions/examination.
", "description": "The health problem or issue experienced by the person resulting in their attendance. This may include disease state, medical condition, response and reactions to therapies. e.g., blackout, dizziness, chest pain, follow up from admission, falls, a specific procedure, investigation or treatment.", "informationType": "Event.Record", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for presenting complaint or issue", "valueSets": "SNOMED CT : - ^1127581000000103 |Health issues simple reference\n set| \n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "valueSets": "Free text", "valueDomain": [{"type": "string", "property": [{"maxLength": "150"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Chief complaint", "implamentationGuidance": "This element is for received information from referrals.\u00a0 For 111 referrals in England this will be free text (should become SNOMED CT in the future) based on the system group or system discriminator codes coming from the triage system used in 111 services, overriding the refset specified in the valueset
", "description": "The nature of the person's chief complaint as assessed by the care professional first assessing the person. Only ONE (chief complaint) sent as per the Chief Complaint code set (SNOMED CT).", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value of the chief complaint", "valueSets": "SNOMED CT: - 991401000000107 | Emergency care presenting complaints or\n issues simple reference set (foundation metadata concept) \n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "description": "Any free text if no coded value is available", "valueSets": "Free text", "valueDomain": [{"type": "text"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Problem list", "implamentationGuidance": "The Problem List section captures inbound information from 111 referrals to the Community Pharmacy and will typically detail more recent relevant history. There may be overlap with the History section regarding the information captured here, but it is important to read the information in both sections to allow a holistic view of the person's\n history.
", "description": "A summary of the problems that require investigation or treatment.", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Problem list record entry", "description": "This is a problem list record entry.SNOMED CT: - <442083009 | Anatomical or acquired body structure (body structure) |
", "description": "The coded value for body site.\u00a0", "valueSets": "SNOMED CT."}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Laterality", "description": "\n^999000821000000100 |Laterality simple reference set (foundation metadata concept)|
", "description": "The coded value for laterality.", "valueSets": "SNOMED CT."}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Stage of disease", "description": "The stage of the disease where relevant.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for stage of disease.", "valueSets": "SNOMED CT."}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Problem status", "description": "The status of the problem. This can be either active or inactive.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for problem status.", "valueSets": "SNOMED CT."}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Problem priority", "description": "The problem priority level. This can be either significant or minor.\u00a0", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for problem priority.\u00a0", "valueSets": "SNOMED CT."}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Problem on discharge", "description": "The main problem or diagnosis on discharge.Free text
", "valueDomain": [{"type": "text"}]}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Procedures and therapies", "description": "The details of any procedures performed. Includes both psychological and medical therapies and procedures (e.g. cognitive behaviour therapy, hip replacement)", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Procedure record entry", "implamentationGuidance": "If the vaccination section of this record is completed, the responses for that section should populate a record entry for this section also.
", "description": "This is a procedure record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.", "informationType": "Event.Record", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Procedure", "description": "The therapeutic or diagnostic procedure performed. Includes both psychological and medical therapies and procedures (e.g. cognitive behaviour therapy, or follow-up interventions as a result of physical health checks). Complementary or alternative procedures and therapies should be recorded here.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implamentationGuidance": "(<71388002 |Procedure| OR <129125009 |Procedure with explicit context| AND NOT ^999002571000000104 |Default exclusion filter simple reference set (foundation metadata concept)|
", "description": "The procedure code.", "valueSets": "\u00a0
"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Specific anaesthesia issues", "description": "Details of any adverse reaction to any anaesthetic agents including local anaesthesia. Problematic intubation, transfusion reaction, etc.
", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for specific anaesthesia issues.
", "valueSets": "SNOMED CT"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Comment", "description": "Any further textual comment to clarify such as statement that information is partial or incomplete. Also indicate the outcome of the procedure.", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Ambulatory blood pressure monitoring offered", "description": "Items to indicate whether ambulatory blood pressure monitoring was offered. If the offer is declined it can also record the reason why.
", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Ambulatory blood pressure monitoring declined", "implamentationGuidance": "861231000000105 |Ambulatory blood pressure recording declined (situation)|
", "description": "A flag to indicate that the offered ambulatory blood pressure monitoring was declined by the service user.
", "valueSets": "861231000000105 |Ambulatory blood pressure recording declined (situation)|
"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Reason for declining ambulatory blood pressure monitoring", "description": "The reason that the service user declined ambulatory blood pressure monitoring.
", "valueSets": "Free text
", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Contraception record entry", "implamentationGuidance": "Gravida and Parity are observables (SNOMED CT).
161732006 |Gravida (observable entity)|
364325004 |Parity (observable entity)|
", "description": "Record entry relating to the patient's use of contraception.
", "informationType": "<p>Event.Record</p>", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contraception type", "description": "The type of contraception used.\u00a0
", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implamentationGuidance": "<<13197004 |Contraception (finding)|
", "description": "The coded value for contraception type.", "valueSets": "SNOMED CT."}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "description": "Free text field to be used if no code is available.", "valueSets": "Free text.", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contraception start date", "description": "The date on which the contraception method was first used by the person.", "valueSets": "Date and time
", "valueDomain": [{"type": "date", "property": [{"timeStampPrecision": "YMD"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contraception end date", "description": "The end date of the contraception method used.", "valueSets": "Date and time
", "valueDomain": [{"type": "date", "property": [{"timeStampPrecision": "YMD"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contraception review date", "description": "The date for which the person's contraception needs to be reviewed.
", "valueSets": "Date and time
", "valueDomain": [{"type": "date", "property": [{"timeStampPrecision": "YMD"}]}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "History", "implamentationGuidance": "The history section is intended to capture SNOMED CT and free text descriptions of patient history recorded by the pharmacist. This should only include history which is pertinent, for example contraindications, pregnancy, immunosuppression etc. There may be overlap with the Problem List section regarding the information captured here, but it\n is important to read the information in both sections to allow a holistic view of the person's history.
", "description": "Information relating to the evolution of each presenting complaint, and the patient's relevant health history.", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Relevant past medical, surgical and mental health history", "description": "The record of the person\u2019s significant medical, surgical and mental health history. Including relevant previous diagnoses, problems and issues, procedures, investigations, specific anaesthesia issues, etc. (will include dental and obstetric history)
A list of the person's relevant past medical, surgical and\n mental health history recorded in free text or coded form or Information relating to past medical, surgical and mental health history may be provided by the referral document or during the consultation.
This item should be used to capture \"Professional discussions undertaken\" where needed.
", "description": "A description detailing a patient\u2019s reason for attendance, results from the diagnostic and treatment process.", "valueSets": "Free text", "valueDomain": [{"type": "text"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Social context", "implamentationGuidance": "This section includes information about the social setting in which the person lives, such as their household, occupational, and lifestyle factors.
", "description": "The social setting in which the person lives, such as their household, occupational history, and lifestyle factors.", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Smoking status", "description": "Details of the person's smoking status.", "informationType": "Event.Record", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Smoking status", "description": "\n\u2018Smoking status\u2019 should be shared using SNOMED CT rather than yes or no.
", "description": "The smoking status of the person.", "valueSets": ""}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Smoking status - details", "description": "Further details recorded about the smoking status of the person", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Smoking record", "description": "Details of the person's smoking record", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Nicotine Replacement Therapy used", "description": "A record of whether nicotine replacement therapy (NRT) is currently used or prescribed in this appointment", "valueSets": "\nNRT not currently used
\nNRT currently used
\nNRT prescribed at this appointment
\n ", "valueDomain": [{"type": "text"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Varenicline or other pharmacotherapy used", "description": "Record of whether varenicline or other smoking cessation pharmacotherapy (other than nicotine replacement therapy) is currently used or prescribed in this appointment.", "valueSets": "\nVarenicline/other pharmacotherapy not used
\nVarenicline/other pharmacotherapy currently used
\nVarenicline/other pharmacotherapy prescribed in this appointment
\n ", "valueDomain": [{"type": "text"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "e-cigarettes used", "description": "Record of current use of e-cigarettes", "valueSets": "\nCoded - SNOMED CT:
\n722499006 |Electronic cigarette user (finding)|
\n "}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Set quit date", "description": "Date set to quit smoking", "valueSets": "390901002 |Negotiated date for cessation of smoking (observable entity)|
"}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Treatments and interventions and changes made to treatments.", "description": "The treatments and interventions carried out. Where appropriate record the rationale for the decision to treat and the information sources reviewed e.g. end of life care plan etc. All medications should be recorded under the medications heading.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for treatment and interventions.", "valueSets": "SNOMED CT"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date stopped smoking", "description": "The date the person stopped smoking (if known)", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for date stopped smoking.", "valueSets": ""}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date", "description": "The date the person stopped smoking.", "valueSets": "Date and time", "valueDomain": [{"type": "datetime", "property": [{"timeStampPrecision": "YMDHM"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Self reported quit", "implamentationGuidance": "New concept to be added from 251900003 |Expired carbon monoxide concentration (observable entity)|
", "description": "A flag to indicate whether the quit was self reported or not.
", "valueSets": "Yes/No
", "valueDomain": [{"type": "boolean"}]}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Family history", "description": "Family history", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Family history record entry", "description": "This is a family history 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.", "informationType": "Event.Record", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Family history", "description": "The record of relevant illness in family relations deemed to be significant to the care or health of the person, including mental illness and suicide, genetic information etc.", "valueSets": "\nFree text
", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Investigation results", "implamentationGuidance": "This section can be used to record carbon monoxide levels for the smoking cessation service.
", "description": "Investigation results", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Investigation results record entry", "description": "This is a investigation result record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.", "informationType": "Event.Record", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Investigation", "description": "The investigation performed.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for investigation", "valueSets": "<363787002 |Observable entity (observable entity)|
", "description": "The value of the investigation result.", "valueSets": "Numeric", "valueDomain": [{"type": "string", "property": [{"maxLength": "10"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Units of measure", "description": "The units of the investigation result.", "valueSets": "UCUM code", "valueDomain": [{"type": "string", "property": [{"maxLength": "10"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Reference ranges", "description": "The reference range for the investigation result.", "valueSets": "Free text", "valueDomain": [{"type": "string"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Abnormal indicator", "description": "Indicator if the investigation is abnormal.", "valueSets": "Abnormal or Normal", "valueDomain": [{"type": "blob"}]}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Signpost details", "implamentationGuidance": "These are the details of any services that the person with has been signposted too. Signposting is in the form of providing the person with the name of an organisation and their contact details e.g. telephone number, website (it is not a referral).
", "description": "Details of signpost", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Signpost details record entry", "description": "This is the signpost 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.", "informationType": "Event.Record", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date", "description": "Date of signpost.", "valueSets": "Date and time
", "valueDomain": [{"type": "datetime", "property": [{"timeStampPrecision": "YMD"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Signpost to", "description": "Details of where the signpost is to.NHS data dictionary :- Activity treatment function code
", "valueDomain": [{"type": "string", "property": [{"maxLength": "70"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Service", "description": "The service signposted to.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implamentationGuidance": "Use <<975131000000104 |Signposting (procedure)|.
", "description": "The coded value for service.", "valueSets": ""}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "description": "Free text field to be used if no code is available.", "valueSets": "Free text.", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "The contact details of where the person has been signposted to.", "valueSets": "Free text.", "valueDomain": [{"type": "string", "property": [{"maxLength": "150"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Reason for signpost", "description": "The reason for signposting.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "description": "Free text field to be used if no code is available.", "valueSets": "Free text.", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Urgency for signpost", "description": "The details of the clinical urgency of signpost.", "valueSets": "\nIt is important that both systolic and diastolic measurements are kept together for each reading. Splitting them up may lead to an inability to pair readings if more than one measurement is taken.
It should be assumed that the person is sitting for their blood pressure reading unless stated otherwise. If the person is not sitting, then\n the appropriate SNOMED code should be used. For example:
Ambulatory blood pressure readings
Lying blood pressure readings
Standing blood pressure readings
Average home blood pressure readings
It should be assumed that the person is sitting for their blood pressure reading unless stated otherwise. If the person is not sitting, then the appropriate SNOMED code should be used. For example:
198081000000101 | Ambulatory systolic blood pressure (observable entity) |
407556006 | Lying systolic blood pressure\n (observable entity) |
400974009 | Standing systolic blood pressure (observable entity) |
413606001 | Average home systolic blood pressure (observable entity) |
Details of the person's diastolic blood pressure
", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implamentationGuidance": "It should be assumed that the person is sitting for their blood pressure reading unless stated otherwise. If the person is not sitting, then the appropriate SNOMED code should be used. For example:
198091000000104 | Ambulatory diastolic blood pressure (observable entity) |
407557002 | Lying diastolic blood\n pressure (observable entity) |
400975005 | Standing diastolic blood pressure (observable entity) |
413605002 | Average home diastolic blood pressure (observable entity) |
The coded value for temperature
", "valueSets": "SNOMED CT : -<<386725007 |Body temperature (observable entity)|The value of the person temperature
", "valueSets": "Numeric", "valueDomain": [{"type": "quantity", "property": [{"minInclude": "1", "maxInclude": "2"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Units of measure", "description": "The units of measure for the persons temperature
", "valueSets": "UCUM code"}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Oxygen saturation ", "description": "The measurement of oxygen within the blood (expressed as a percentage of 100)", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for Oxygen saturation", "valueSets": "SNOMED CT: - 431314004 |Peripheral oxygen saturation (observable entity)|"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Value", "description": "The value for the persons oxygen saturation", "valueSets": "Numeric", "valueDomain": [{"type": "quantity", "property": [{"maxInclude": "3"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Units of measure", "description": "The units of measure for oxygen saturation", "valueSets": "UCUM code", "valueDomain": [{"type": "string", "property": [{"maxLength": "3"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Pain score", "description": "The pain score for the person", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value ", "description": "The coded value for pain score", "valueSets": "SNOMED CT : -\u00a0225908003 | Pain score (observable entity) |"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Value", "description": "The value for the pain score", "valueSets": "Numeric", "valueDomain": [{"type": "quantity"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Units of measure", "description": "The units of measure for pain score", "valueSets": "UCUM", "valueDomain": [{"type": "quantity"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Level of consciousness", "description": "Person's level of arousal and awareness", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "\n\n Coded value for level of consciousness\n
\n ", "valueSets": "SNOMED CT : -\u00a0 1104441000000107 | Alert Confusion Voice Pain Unresponsive scale score (observable entity) | \n\n \n
\n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Value", "description": "Value of the level of consciousness", "valueSets": "Numeric", "valueDomain": [{"type": "quantity"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Units of measure ", "description": "Unit of measure for level of consciousness", "valueSets": "UCUM", "valueDomain": [{"type": "quantity"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Respiratory rate", "description": "Number of breaths you take per minute| \n \n \n \n \n SNOMED CT : -\u00a086290005 | Respiratory rate (observable entity) | | \n
If the person is on Air or Oxygen
", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for Air or Oxygen", "valueSets": "SNOMED CT: -\u00a0722742002 |Breathing room air| OR 371825009 |Patient on oxygen| OR 315041000 | High concentration oxygen therapy (procedure) | OR 9999016 | High flow oxygen therapy (procedure) |"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Value", "description": "The value for air or oxygen", "valueSets": "Free text", "valueDomain": [{"type": "quantity", "property": [{"maxInclude": "10"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Units of measure", "description": "The unit of measure for the air or oxygen value", "valueSets": "UCUM", "valueDomain": [{"type": "string", "property": [{"maxLength": "10"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "National early warning score (NEWS 2)", "implamentationGuidance": "This element can be used to record NEWS 2, PEWS, or MEWS. It is important to ensure that nested algorithms are implemented correctly for this element, as failure to do so may lead to suboptimal care. Further information about NEWS 2 can be found on the Royal College of Physicians website. You can also find more information about NEWS 2 systems in Nice Guidance.
", "description": "\nThis record can be used to record NEWS 2, PEWS, or MEWS.
", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value total score", "description": "The coded value for NEWS 2 total score", "valueSets": "SNOMED CT : -\u00a01104051000000101 | Royal College of Physicians National Early Warning Score 2 total score (observable entity) |"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Value for total score", "description": "The actual NEWS 2 score.", "valueSets": "Numeric", "valueDomain": [{"type": "quantity"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Coded value subscore", "description": "Coded value for the subscore", "valueSets": "SNOMED CT : -\u00a01104301000000104 | Royal College of Physicians National Early Warning Score 2 - respiration rate score (observable entity) |<<364769008 |Finding of infant feeding method (finding)|
", "description": "The coded value for feeding status of the baby.", "valueSets": "NHS data dictionary : - Breastfeeding status .This section can be used to record inbound assessments from referrals; e.g. Fagerstrom Scores for the Smoking Cessation Service.
", "description": "Details of the person's assessments", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "name": "Assessments record entry", "description": "This is the assessments record entry. There may be 0 to many record entry/entries under a section. Each record entry is made up of a number of elements or data items.", "informationType": "Event.Record", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Assessment type", "description": "The type of the assessment e.g. social care needs assessment.", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Assessment summary", "description": "The summary of the assessment", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "250"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Structured assessment", "description": "Details of the structured assessment.", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Structured assessment name", "description": "Structured assessment name e.g. New York Heart Failure, Glasgow Coma scale, Activities of Daily Living (ADL) etc.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for structured assessment name.\u00a0", "valueSets": "Patients may return to/contact the pharmacy if they experience a reaction at a later date in relation to a vaccination or supply of medicine. Further consideration should be given about how to notify GPs where an allergic/adverse reaction occurs after the patient has left the pharmacy.
", "description": "Allergies and adverse reactions", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Allergies and adverse reactions record entry", "implamentationGuidance": "Existing allergies should not be duplicated. Allergies should only be recorded and communicated to the patient\u2019s GP where the pharmacist thinks that the allergy has been newly identified. In this situation, pharmacists should check against SCR/ShCRs for any existing allergy details before reporting it is as new allergy. Guidance on good\n practice recording of allergies and adverse reactions is provided by NICE (https://www.nice.org.uk/guidance/CG183/chapter/1-Recommendations). This relates to end systems rather than the transfer of care communication but is included here as its use\n should improve the quality of the information communicated.
", "description": "This is a allergies and adverse reactions record entry. There may be 1 to many record entries under a section.Coded information on causative agents is important to GPs to enable safe operation of prescribing decision support. The model proposed here is being adopted across the GP domain to enable interoperable drug allergy information to support patient safety at transfer of care.
", "description": "The coded value for causative agent", "valueSets": "| \n \n \n dm+d:- any code from the VTM, VMP, AMP, VMPP, AMPP and ingredient concept classes \n |
In future, medication information will be captured by scanning the GS1 barcode of the medicine. Additional information on GS1 is available at https://www.gs1uk.org/standards-services/standards.
", "description": "Medications and medical devices", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Medication item entry", "implamentationGuidance": "Please note that this section can be used to record any medication that is provided through CPCF services, and is not limited to prescribed medication.
", "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.", "informationType": "Event.Record", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Medication item cluster", "description": "Medication item cluster", "informationType": "Event.Record", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date", "description": "The date on which the medication or medical device was prescribed.", "valueSets": "Date and time", "valueDomain": [{"type": "datetime", "property": [{"timeStampPrecision": "YMDHM"}]}]}, {"type": "group", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "M", "name": "Medication name", "description": "May be generic name or brand name.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for medication name", "valueSets": "dm+d:- any code from the VTM, VMP, AMP, VMPP and AMPP concept classes"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Form", "description": "The form of the medication e.g. capsule, drops, tablet, lotion etc.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for form.", "valueSets": ""}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "group", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "M", "name": "Quantity supplied", "implamentationGuidance": "The total amount of medication supplied should be recorded in a structured format, as per common current practice.
", "description": "The quantity of the medication (e.g. tablets, inhalers, etc.) provided to the person. This may be dispensed by the pharmacy or on the ward. Record in a structured format i.e. value and a unit", "valueSets": "Free text", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Value", "description": "The value of the quantity supplied", "valueSets": "Enumerated value", "valueDomain": [{"type": "quantity"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Units of measure", "description": "\nThe days or period prescribed/supplied should be recorded as a numeric value under the heading \u2013 e.g., 5 days.
", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Supply period value", "description": "The numeric value of the supply period.
", "valueSets": "Enumerated value
", "valueDomain": [{"type": "quantity"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Supply period units", "description": "The units for the supply period.
", "valueSets": "Hour(s)
Day(s)
Week(s)
Month(s)
Site should be auto populated where possible to reduce burden on the pharmacist.
", "description": "The anatomical site at which the medication is to be administered.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for site", "valueSets": ""}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "description": "Free text field to be used when code is not available", "valueSets": "Free text", "valueDomain": [{"type": "string", "property": [{"maxLength": "150"}]}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Supply type", "implamentationGuidance": "Supply type is a heading which identifies the type of medication supply. The following value set has been proposed as part of the NHS Digital curation process: https://fhir.hl7.org.uk/STU3/ValueSet/CareConnect-MedicationSupplyType-1.
", "description": "A description of the type of supply (e.g. emergency supply, over the counter medication, patient group direction etc)"}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Batch number", "description": "The batch number of the product.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for the batch number", "valueSets": "FMD code : - Derived from Falsified medicines directive"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Structured dose direction cluster", "description": "A structural representation of the elements carried by the dose syntax in 'parsable dose strength / timing' i.e. dose strength, dose timing, dose duration and maximum dose.", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Structured dose amount", "description": "The \u2018dose directions description\u2019 can now be recorded in a structured way with free text an option for systems unable to manage structured data. Dose syntax should be unambiguous and avoid using confusing abbreviations.
", "description": "Describes the entire medication dosage and administration directions including dose quantity and medication frequency and optionally duration e.g. \u201c1 tablet at night\" or \u201c2mg at 10pm\u201d.", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Additional instructions", "implamentationGuidance": "Additional instructions should be auto populated where possible to reduce burden on the pharmacist.
", "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.", "valueSets": "FHIR value set : - Additional instruction \n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Matters identified during discussion", "description": "Matters identified during the service about the patient's experience of using the medication.", "valueSets": "\nIf possible, implement this as a multiple-choice value set with the option for text in the case of \"Other (Please specify)\". Potentially to be SNOMED coded in the future.
", "description": "The reason why the patient is requesting a supply of medication or medical appliance.
", "valueSets": "A- Patient had not ordered their prescription
B- Patient had ordered their prescription but it was not ready
C- Patient had lost prescription form
D- Patient had lost or misplaced the medicine(s) or appliance(s)
E- Patient was not able to collect the medicine(s) or\n appliance(s) (from their usual pharmacy)
F- Patient is away from home (and had forgotten/did not bring sufficient supplies of their medicine(s) or
appliance(s))
G- Other (please specify)
", "valueDomain": [{"type": "text"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "No supply reason", "implamentationGuidance": "This item can be used for both the contraception service and the community pharmacist consultation service. Different valuesets are used for each of the services. When one of these services is being carried out, please ensure the correct valueset is being used.
Contraception Service
A - \"Consent not\n given\"
B - \"Individuals under 16 years of age and assessed as not competent using Fraser Guidelines\"
C - \"Individuals 16 years of age and over and assessed as lacking capacity to consent\"
D - \"Known or suspected pregnancy\"
E - \"Known hypersensitivity to the active ingredient or to any constituent of the product\"
F - \"Less 21 days\n after childbirth\"
G - \"Less than 5 days after miscarriage, abortion, ectopic pregnancy or uterine evacuation for gestational trophoblastic disease (GTD)\"
H - \"Breastfeeding and less than six weeks postpartum\"
I - \"Interacting medicines\"
J - \"Cardiovascular disease related\"
K - \"Neurological condition related\"
L - \"Cancer\n related\"
M - \"Gastro-intestinal condition related\"
N - \"Related to other health conditions\"
O - \"DVT risk concerns\"
P - \"Above target blood pressure or BMI\"
Q - \"Patient outside approved PGD age range\"
R - \"Requires oral contraception not covered by PGD\"
S - \"Requires initiation onto oral contraception\"
T - \"Other\n (please state)\"
Community Pharmacist Consultation Service
A - \"Item not able to be supplied under emergency supply regulations (e.g.
Schedule 1, 2 or 3 Controlled Drug)\"\"
B - \"EPS prescription dispensed for patient\"\"
C - \"Pharmacist determined that supply not necessary (e.g. not clinically appropriate or concern\n about abuse of service)\"
D - \"Item not in stock
F - \"Patient bought the item\"
G - \"Other (please state)\"
", "description": "The reason that medication has not been supplied.
"}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Course details cluster", "description": "Details of the overall course of medication.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Indication", "description": "Reason for medication being prescribed, where known.", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Prescription exemption category", "description": "A record of whether the patient is exempt from NHS prescription charges.
", "valueSets": "\"\"\"A. 60 years of age or over or is under 16 years of age\"\"
\"\"B. 16, 17 or 18 and in full time education\"\"
\"\"D. Maternity exemption certificate\"\"
\"\"E. Medical exemption certificate\"\"
\"\"F. Prescription prepayment Certificate (PPC)\"\"
\"\"G. Prescription exemption\n certificate issued\"\" by Ministry of Defence
\"\"L. HC2 (full help) certificate\"\"
\"\"H. Income Support (IS) or Income-related\"\" \"\"Employment and Support Allowance (ESA)\"\"
\"\"K. Income-based Jobseeker\u2019s Allowance (JSA)\"\"
\"\"M. Tax Credit exemption certificate\"\"
\"\"S. Pension Credit Guarantee Credit\"\"
\"\"U. Universal Credit and meets\n the criteria\"\"
\"\"X. Free-of-charge contraceptives\"\"
\"\"Pays for each prescription item\"\"
\"\"HMP - Prisoner on release or released from secure accommodation\"\"\"
"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Prescriptions intercepted", "description": "Confirmation of whether the pharmacist intercepted any prescriptions to prevent the patient receiving inappropriate supply.
", "valueSets": "\"Prescription(s) intercepted\"
\"Prescription(s) not intercepted\"
"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Information and advice given", "implamentationGuidance": "In some instances, specific information about the information and advice which was given to the patient (e.g., proper inhaler technique) may want to be communicated to the recipient. It is important that this is concise and is only information which it is pertinent for the recipient to be aware of. Where patients are provided with literature\n (e.g., pamphlets) there is no need to provide details of the information contained in the literature e.g., simply state that the patient was provided with a pamphlet. The system should provide an easy way to view and select common information and advice given to individuals e.g., after care instructions, common side effects etc.\u201d is included in the\n implementation guidance for information and advice given.
", "description": "Information and advice given.", "informationType": "Event.Record", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Information and advice given", "description": "The oral, written, or multi-media information or advice given to the person, carer, other authorised representative, care professional or other third party. May include advice about actions related to medicines or other ongoing care activities on an \u2018information prescription'. State here if there are concerns about\n the extent to which the person and/or carer understand the information provided about diagnosis, prognosis and treatment.
", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implamentationGuidance": "<<418043000 |Advice given (situation)|
", "description": "The coded value for information and advice given.", "valueSets": "SNOMED CT."}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Plan and requested actions", "implamentationGuidance": "The plan should make clear who is expected to take responsibility for actions following the encounter, e.g., the person receiving care or their carers; the GP or another heath care professional.
The pharmacy provided plan could be presented in several ways in the system to prompt complete information to be recorded e.g., table, best\n practice prompts, etc.
This section may include the date of the next planned review.
", "description": "The details of planned investigations, procedures and treatment, and whether this plan has been agreed with the person or their legitimate representative.", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Plan and requested actions record entry", "description": "This is a plan and requested actions 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.", "informationType": "Event.Record", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Actions for professionals", "description": "Including planned investigations, procedures and treatment for a person's identified conditions and priorities. For each action the following should be identified:outcome expectations, including the person\u2019s expectations. A record of the planned and requested actions. May be structured (table), with actions, names, dates, status, location,\n strategies.", "valueSets": "Free text", "valueDomain": [{"type": "text"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Actions for person or their carer", "description": "For each action the following should be identified:outcome expectations, including person\u2019s expectations. A record of the planned and requested actions. May be structured (table), with actions, names, dates, status, location, strategies.", "valueSets": "Free text", "valueDomain": [{"type": "text"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Documents (including correspondence, audio and images)", "implamentationGuidance": "This section has been included to ensure that information from documents, such as ABPM reports, can be stored in the pharmacy record.
", "description": "Details about documents related to the person.", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Documents", "description": "This is the documents record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.", "informationType": "Event.Record", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Documentation location", "description": "The location of the document", "valueSets": "Free text or URL", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Document name", "description": "The name of the document. This should align to the PRSB document naming standard. Where the document is a KOS document this field (designated typeCode) is used to carry the DICOM Imaging procedure: This attribute shall be populated by the XDS-I Imaging Document Source from a code in the Procedure Code Sequence (0008,1032) of the performed procedure\n with which the document is associated. Values may be found in a suitable DICOM browser", "valueSets": "SNOMED CT: - As per the https://theprsb.org/wp-content/uploads/2018/11/Clinical-document-indexing-standards_NHS-Scotland.pdf \n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Comments", "description": "Comments associated with the document.", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Red flags", "implamentationGuidance": "The pharmacist will ensure that any relevant \u2018Red Flags\u2019 are recognised and responded to as part of the consultation process. \u2018Red flags\u2019 are detailed at https://cks.nice.org.uk/\n
", "description": "Record entry for red flags that have been identified during service provision.
", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Red flags", "description": "Confirmation of whether any red flags (i.e. symptoms that suggest more serious illness) were identified.
", "valueSets": "Flag:- a. \"Yes\" b. \"No\"
", "valueDomain": [{"type": "boolean"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Red flag detail", "description": "Details of red flag symptoms recorded if the 'Red flags' were identified as \"Yes\".
", "valueSets": "Free text
", "valueDomain": [{"type": "string", "property": [{"maxLength": "150"}]}]}]}]}]}