{ "dataset": [ { "version": "2.01", "name": "Core information standard", "concept": [ { "type": "group", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "M", "name": "Person demographics", "implementationGuidance": "This section contains the person’s demographic and contact details including key identifiers (e.g., name, date of birth, sex at birth, NHS number, address etc.). It also includes a person’s gender identity and pronouns, where stated. \u003Cbr clear=\"none\"/\u003E \n •\tNHS number (or equivalent, e.g. CHI number in Scotland) is likely to be the primary identifier however existing national guidance should be followed, including how to handle patients without an NHS number, for example, overseas visitors. \u003Cbr clear=\"none\"/\u003E \n •\tThe PDS (Personal Demographics Service) should be used as the source of this information. The mandatory information in this section is person’s name, sex at birth, date of birth and address. There can be multiple addresses associated with a person including temporary and correspondence addresses. \u003Cbr clear=\"none\"/\u003E \n •\tTo improve the accuracy of the organ and tissue donation element systems should link directly to the organ donation register where possible. \u003Cbr clear=\"none\"/\u003E \n ", "description": "The person's details and contact information.", "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": "*", "mro": "M", "name": "Person first name", "description": "The first name(s) of the person. This includes middle names.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/person_given_name.html?hl=person%2Cgiven%2Cname\" target=\"\" title=\"\"\u003EPerson given name\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] }, { "type": "item", "minimumMultiplicity": "1", "maximumMultiplicity": "*", "mro": "M", "name": "Person family name", "description": "The family name or surname of the person", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/person_family_name.html\" target=\"\" title=\"\"\u003EPerson family name\u003C/a\u003E \n \u003Cbr clear=\"none\"/\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person preferred name", "description": "The name by which a person wishes to be addressed. The preferred name volunteered by the person or a preferred name given by PDS that the person has asked to be called by.", "valueSets": "NHS data dictionary: - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/person_full_name.html?hl=person%2Cname\" target=\"\" title=\"\"\u003EPerson full name\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Title", "description": "Person's title", "valueSets": "NHS data dictionary: - \u003Ca href=\"https://www.datadictionary.nhs.uk/data_dictionary/data_field_notes/p/pers/person_title_de.asp?shownav=1\" target=\"\" title=\"\"\u003EPerson title\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Person name suffix", "description": "A textual suffix that may be added to the end of a PERSON's name, for example, OBE, MBE, BSc, JP, GM", "valueSets": "NHS data dictionary: - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/person_name_suffix.html\" target=\"\" title=\"\"\u003EPerson suffix\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person full name", "description": "The full name of the person in text representation.", "valueSets": "NHS data dictionary :- \u003Ca class=\"\" href=\"https://datadictionary.nhs.uk/data_elements/person_full_name.html?hl=person%2Cname\" target=\"\" title=\"\"\u003EPatient full name\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] } ] }, { "type": "item", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "M", "name": "Date of birth", "description": "The date of birth of the person.", "valueSets": "NHS data dictionary:- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/person_birth_date.html?hl=person%2Cbirth%2Cdate\" target=\"\" title=\"\"\u003EPerson birth date\u003C/a\u003E \n ", "valueDomain": [ { "type": "date", "property": [ { "timeStampPrecision": "YMD!" } ] } ] }, { "type": "item", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "M", "name": "Sex at birth (observed)", "implementationGuidance": "This is as observed by clinical examination and assessment at birth. Where there is no health and care record from birth, and clinical examination and assessment is not possible, this can be stated by the person or proxy. \u003Cbr clear=\"none\"/\u003E \n ", "description": "The phenotypic sex of the person.", "valueSets": "NHS data dictionary : - \u003Ca class=\"\" href=\"https://www.datadictionary.nhs.uk/data_elements/person_phenotypic_sex.html\" target=\"\" title=\"\"\u003EPerson phenotypic sex\u003C/a\u003E \n ", "valueDomain": [ { "type": "code", "property": [ { "maxLength": "1" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Administrative gender", "implementationGuidance": "• This is a legacy data item for England only to represent the data held on the Personal Demographics Service (PDS). NHS England is reviewing the data items in PDS so this will be replaced. \u003Cbr clear=\"none\"/\u003E \n • This data item should be read-only. \u003Cbr clear=\"none\"/\u003E \n • In the majority of cases ‘Administrative gender’ and ‘Sex at birth (observed)’ would be the same. However, in some cases displaying both ‘Administrative gender’ and ‘Sex at birth (observed)’ would mean that transgender status could be inferred. Implementers should seek information governance advice on when and to whom access can be given to a person’s record (or specific data within a person’s record) where information in the record indicates transgender, non-binary or gender diverse status. \u003Cbr clear=\"none\"/\u003E \n ", "description": "This is the ‘Person Administrative Gender’ held on the Personal Demographics Service (PDS).", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://www.datadictionary.nhs.uk/data_elements/person_gender_code_current.html\" target=\"\" title=\"\"\u003EPerson gender code current\u003C/a\u003E \n \u003Cbr clear=\"none\"/\u003E \n ", "valueDomain": [ { "type": "code", "property": [ { "maxLength": "1" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Ethnicity", "description": "The ethnicity of the person as specified by the person.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/ethnic_category.html\" target=\"\" title=\"\"\u003EEthnic category\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "2" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Religion", "description": "The religious affiliation as specified by the person.", "valueSets": "\n \u003Cdiv\u003ESNOMED_CT:- \u003Ca class=\"\" href=\"https://termbrowser.nhs.uk/?perspective=full&conceptId1=999000531000000100&edition=uk-edition&server=https://termbrowser.nhs.uk/sct-browser-api/snomed&langRefset=999001261000000100,999000691000001104\" target=\"\" title=\"\"\u003EReligion\u003C/a\u003E\n \u003Cbr clear=\"none\"/\u003E\n \u003C/div\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "NHS number", "description": "The unique identifier for a person within the NHS in England and Wales.", "valueSets": "NHS data dictionary:- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/nhs_number.html\" target=\"\" title=\"\"\u003ENHS number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "10" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "NHS number status indicator", "description": "Provides an indication of the reliability of an NHS Number.", "valueSets": "NHS data dictionary :- \u003Ca class=\"\" href=\"https://www.datadictionary.nhs.uk/data_dictionary/attributes/n/nhs/nhs_number_status_indicator_code_de.asp?shownav=1\" target=\"\" title=\"\"\u003ENHS number status indicator\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "2" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Other identifier", "description": "Country specific or local identifier, e.g. Community Health Index (CHI) in Scotland.", "valueSets": "\n \u003Cdiv\u003ENHS data dictionary: - \u003Ca class=\"\" href=\"https://datadictionary.nhs.uk/data_elements/local_patient_identifier__extended_.html?hl=local%2Cpatient%2Cidentifier%2Cextended\" target=\"\" title=\"\"\u003ELocal patient identifier(extended)\u003C/a\u003E, \u003Ca class=\"\" href=\"https://datadictionary.nhs.uk/data_elements/health_and_care_number.html\" target=\"\" title=\"\"\u003EHealth and care number (NI only)\u003C/a\u003E, \u003Ca class=\"\" href=\"https://datadictionary.nhs.uk/data_elements/community_health_index_number.html\" target=\"\" title=\"\"\u003ECommunity health index number\u003C/a\u003E (Scotland only)\u003C/div\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "20" } ] } ] }, { "type": "group", "minimumMultiplicity": "1", "maximumMultiplicity": "*", "mro": "M", "name": "Person's address", "description": "Person’s usual place of residence, and where relevant temporary and correspondence addresses.", "concept": [ { "type": "item", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "M", "name": "Address line 1", "description": "Person's first line of address.", "valueSets": "\n \u003Cdiv\u003ENHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/patient_usual_address.html\" target=\"\" title=\"\"\u003EAddress line 1\u003C/a\u003E\n \u003Cbr clear=\"none\"/\u003E\n \u003C/div\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Address line 2", "description": "Person's second line of address.", "valueSets": "\n \u003Cdiv\u003ENHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/patient_usual_address.html\" target=\"\" title=\"\"\u003EAddress line 2\u003C/a\u003E\n \u003Cbr clear=\"none\"/\u003E\n \u003C/div\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Address line 3", "description": "Person's third line of address.", "valueSets": "\n \u003Cdiv\u003ENHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/patient_usual_address.html\" target=\"\" title=\"\"\u003EAddress line 3\u003C/a\u003E\n \u003C/div\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Address line 4", "description": "Person's fourth line of address.", "valueSets": "\n \u003Cdiv\u003ENHS data dictionary : - \u003Ca class=\"\" href=\"https://datadictionary.nhs.uk/data_elements/patient_usual_address.html\" target=\"\" title=\"\"\u003EAddress line 4\u003C/a\u003E\n \u003Cbr clear=\"none\"/\u003E\n \u003C/div\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Address line 5", "description": "Person's fifth line of address.", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/patient_usual_address.html\" target=\"\" title=\"\"\u003EAddress line 5\u003C/a\u003E \n \u003Cbr clear=\"none\"/\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Postcode", "description": "The person's postcode.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/postcode_of_usual_address.html\" target=\"\" title=\"\"\u003EPostcode of usual address\u003C/a\u003E \n \u003Cbr clear=\"none\"/\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "8" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Address type", "description": "The type of address e.g. Main address, Temp address", "valueSets": "NHS data dictionary : - \u003Ca class=\"\" href=\"https://www.datadictionary.nhs.uk/data_dictionary/attributes/a/add/address_association_type_de.asp?shownav=1\" target=\"\" title=\"\"\u003EAddress association type\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "1" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person's contact details", "description": "Details of the person's contact information.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Preferred contact method", "description": "Preferred contact method, e.g. email, letter, phone, text message etc.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://www.datadictionary.nhs.uk/data_dictionary/attributes/c/com/communication_contact_method_de.asp?shownav=1\" target=\"\" title=\"\"\u003ECommunication contact method\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "1" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Person's telephone number details", "description": "The person's telephone number details", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person's telephone number", "description": "The person's telephone number", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html\" target=\"\" title=\"\"\u003EUK telephone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person's telephone number type", "description": "The contact type e.g. home, mobile", "valueSets": "FHIR value set: - \u003Ca href=\"http://hl7.org/fhir/stu3/codesystem-contact-point-use.html\" target=\"\" title=\"\"\u003EContact point use\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "6" } ], "example": [ { "type": "valid", "#text": "Home" }, { "type": "valid", "#text": "Mobile" }, { "type": "valid", "#text": "Temp" }, { "type": "valid", "#text": "Old" }, { "type": "valid", "#text": "Work" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Preference of telephone number", "description": "The preferred order of use for the telephone number", "valueSets": "Preference of use 1-5, 1 being the highest." } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Person's email address details", "description": "Details of the person's email address", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person's email address", "description": "Email address of the person.", "valueSets": "NHS data dictionary :- \u003Ca\u003EContact email address\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "255" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person's email address type", "description": "The type of email address, home, work", "valueSets": "FHIR value set: - \u003Ca href=\"http://hl7.org/fhir/stu3/codesystem-contact-point-use.html\" target=\"\" title=\"\"\u003EContact point use\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "6" } ], "example": [ { "type": "valid", "#text": "Home" }, { "type": "valid", "#text": "Work" }, { "type": "valid", "#text": "old" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Preference of email address", "description": "The preferred order of use of email address", "valueSets": "Preference of use 1-5, 1 being the highest." } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Other contact information", "description": "Contact details via fax, sms, url", "valueSets": "NHS data dictionary:- \u003Ca href=\"https://datadictionary.nhs.uk/attributes/communication_contact_string.html\" target=\"\" title=\"\"\u003ECommunication contact string\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "255" } ] } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Gender identity", "implementationGuidance": "• Gender identity should ONLY be recorded if a person has a gender identity and wants it recorded in their healthcare record and a clinician decides it is appropriate to record it. If gender identity has been recorded it should be shared. \u003Cbr clear=\"none\"/\u003E \n • The term ‘gender identity’ refers to some people’s sense that they identify as a member of the male or female sex or as neither (or something else), particularly when this identity is different from their sex at birth. It refers to how individuals understand themselves. Gender identity is always expressed by the person themselves. \u003Cbr clear=\"none\"/\u003E \n • This is a legacy value set. NHS England is reviewing the value sets so this will change. \u003Cbr clear=\"none\"/\u003E \n • Displaying both ‘Gender identity’ and ‘Sex at birth (observed)’ would mean that transgender status could be inferred. Implementers should seek information governance advice on when and to whom access can be given to a person’s record (or specific data within a person’s record) where information in the record indicates transgender, non-binary or gender diverse status. \u003Cbr clear=\"none\"/\u003E \n ", "description": "The person's stated gender identity.", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://www.datadictionary.nhs.uk/data_elements/gender_identity_code.html\" target=\"\" title=\"\"\u003EGender identity code\u003C/a\u003E \n \u003Cbr clear=\"none\"/\u003E \n ", "valueDomain": [ { "type": "code", "property": [ { "maxLength": "1" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Additional information about gender identity", "implementationGuidance": "• Information about gender identity should ONLY be recorded if a person has a gender identity and wants additional information about it recorded in their healthcare record and a clinician decides it is appropriate to record it. \u003Cbr clear=\"none\"/\u003E \n • If additional information about a person’s gender identity has been recorded it should be shared. \u003Cbr clear=\"none\"/\u003E \n ", "description": "Any additional information stated by the person about their gender identity.", "valueSets": "Free text", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Pronouns", "implementationGuidance": "• Pronouns should ONLY be recorded if a person wants their pronouns recorded in their healthcare record and a clinician decides it is appropriate to record them. \u003Cbr clear=\"none\"/\u003E \n • If pronouns have been recorded they should be shared. \u003Cbr clear=\"none\"/\u003E \n ", "description": "The person's stated pronouns.", "valueSets": "Free text", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Photograph", "description": "A photograph of the person for identification and to show what the person looks like normally.", "valueSets": "Multimedia file", "valueDomain": [ { "type": "identifier" } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Place of birth", "description": "The country of birth of the person.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://www.datadictionary.nhs.uk/data_dictionary/attributes/c/cou/country_code_de.asp?shownav=1\" target=\"\" title=\"\"\u003ECountry code (birth)\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Marital status", "description": "An indicator to identify the legal marital status of the person.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://www.datadictionary.nhs.uk/data_elements/person_marital_status.html?hl=marital%2Cstatus\" target=\"\" title=\"\"\u003EPerson marital status\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "1" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Immigration status", "description": "Include details of the immigration status of the person, their permissions to live and receive care and support in the UK e.g. asylum seeker, indefinite leave to remain in the UK. Include start date, end date and any comments.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Immigration status", "description": "Details of the immigration status of the person, their permissions to live and receive care and support in the UK e.g. asylum seeker, indefinite leave to remain in the UK.", "valueSets": "Code :- 1: Asylum Seeker; 2: Exceptional leave to remain in UK; 3: Indefinite Leave to Remain in UK ;4: Limited Leave to Remain in UK; 5: No Recourse to Public Funds (NRPF); 6: Other Nationals; 7: Refugee; 8: Unaccompanied Asylum Seeker; 9 EU pre-settled status; 10: EU settled status" }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Start date", "description": "Start date of immigration status", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "End date", "description": "End date of immigration status", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Comment", "description": "Relevant comments about the person's immigration status", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organ and tissue donation", "description": "Whether the person has given consent for organ and/or tissue donation or opted out of automatic donation where applicable. This is information provided by the national register.", "valueSets": "Flag: - Yes or No", "valueDomain": [ { "type": "boolean" } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Overseas visitor status", "description": "The charging category relating to an overseas visitor.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/overseas_visitor_charging_category.html\" target=\"\" title=\"\"\u003EOverseas visitor charging catergory\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "1" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "M", "name": "GP practice", "implementationGuidance": "This section contains details of the GP practice where the person is registered. This information would be sourced from PDS. This will include the GP practice identifier code. In situations where a person is not registered with a GP practice, the GP practice identifier would contain the appropriate code to indicate this. This section would also need to accommodate details for temporary GP where the patient is registered away from their usual place of residence \u003Cbr clear=\"none\"/\u003E \n • ‘GP practice identifier’ does not need to be a displayed field. It is intended to be used to provide the GP practice details via lookup from national registers. \u003Cbr clear=\"none\"/\u003E \n • Many people will not offer a named GP. Only the ‘GP practice details’ section would need to be completed in these situations. \u003Cbr clear=\"none\"/\u003E \n • A patient may be registered with more than one GP practice. Normally patients are registered with one practice, but may be treated as a temporary registration (e.g. whilst on holiday) by another practice. The registered GP practice can be obtained from the PDS. Suppliers should enable more than one GP practice to be recorded to accommodate temporary registration. Communications will go to the GP surgery that the patient is permanently registered with. However, sometimes a GP who is serving a patient on a temporary basis may also need to access the transfer of care communication. In this instance, both GP practices should be recorded. \u003Cbr clear=\"none\"/\u003E \n • If a patient is not registered with a GP practice, then the GP practice record entry should appear with the text \"No known GP practice\". \u003Cbr clear=\"none\"/\u003E \n ", "description": "Details of the person's GP practice.", "concept": [ { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "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", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "GP name", "description": "The name of the person's GP. If the person is registered with a GP practice, their usual GP name will be something volunteered by the person or their representative.", "valueSets": "Free text", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "GP practice details", "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", "description": "The identifier of the registered GP practice.", "valueSets": "\n \u003Cdiv\u003ENHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/general_medical_practice_code__patient_registration_.html?hl=general%2Cmedical%2Cpractice%2Ccode%2Cpatient%2Cregistration\" target=\"\" title=\"\"\u003EGeneral medical practice code (patient registration)\u003C/a\u003E\n \u003Cbr clear=\"none\"/\u003E\n \u003C/div\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "6" } ] } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "About me", "implementationGuidance": "This section supports sharing of information that the person thinks it is important to share with professionals. This could include information about their needs, preferences, concerns and wishes. For example, it could include that a person has a pet that would need looking after were they to go into hospital. For more detailed implementation guidance please look at the following link https://theprsb.org/wp-content/uploads/2021/06/About-Me-Implementation-Guidance-v1.4.pdf \u003Cbr clear=\"none\"/\u003E \n ‘About me’ should be prominently displayed in the record as it is important information about the person relevant to all care and support providers. This information may be available in multimedia formats e.g. jpeg, mp3 etc. These documents are likely to follow a variety of formats but should be transferred in their entirety. \u003Cbr clear=\"none\"/\u003E \n Care will need to be taken in local implementations to differentiate between ‘About me’ and things like ‘Advance Directives’ and preferences and wishes expressed in other care plans such as end of life plans. \u003Cbr clear=\"none\"/\u003E \n ", "description": "About me", "concept": [ { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "What is most important to me", "description": "A description of what is most important to you. \u003Cbr clear=\"none\"/\u003E \n ", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "What is most important to me", "description": "\n \u003Cspan style=\"color: rgb(51, 51, 51); font-family: Arial, Helvetica, Geneva, sans-serif; font-size: 12px;\"\u003EA description of what is most important to you \u003Cbr clear=\"none\"/\u003E\n \u003C/span\u003E \n \u003Cb\u003EEmergency Information : -\u003C/b\u003E Include any essential information that any professional in health and social care should know about the you in any situation, including emergencies. \u003Cbr clear=\"none\"/\u003E \n \u003Cspan style=\"font-weight: bold;\"\u003EOther Information : -\u003C/span\u003E This could include : - Values, Spirituality/religion, Ethnicity, Culture, Pets, Goals and aspirations, Meaningful activities including leisure activities, visiting places, sport and exercise, listening to music, employment, education, volunteering", "valueSets": "Free text", "valueDomain": [ { "type": "text" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "People who are important to me", "description": "Details of who is important to you and why. ", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "People who are important to me", "description": "Details of who is important to you and why. They could be family members, carers, friends, members of staff etc. Include how you want the people important to you to be engaged and involved in your care and support in both emergency and normal situations. Include how you stay connected to the people important to you. Who should not be contacted or consulted about your care and support and why, if you wish to say", "valueSets": "Free text ", "valueDomain": [ { "type": "text" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "How I communicate and how to communicate with me", "description": "A description of how you communicate normally. ", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "How I communicate and how to communicate with me", "description": "\n \u003Cp\u003EA description of how you communicate normally including any communication aids you use, for example a hearing aid.\u003C/p\u003E \n \u003Cul\u003E\n \u003Cli\u003EInclude your preferred language of communication, if your first language is not English.\u003C/li\u003E\n \u003Cli\u003EInclude how you would communicate when you are in pain or distress.\u003C/li\u003E\n \u003Cli\u003EInclude how you communicate choices.\u003C/li\u003E\n \u003Cli\u003EInclude how you give feedback or raise a concern.\u003C/li\u003E\n \u003Cli\u003EInclude how you like to receive information\u003C/li\u003E\n \u003C/ul\u003E \n \u003Cp\u003EDescribe how you would like others to engage and communicate with you, including how you would like to be addressed.\u003C/p\u003E \n ", "valueSets": "Free text", "valueDomain": [ { "type": "text" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "My wellness", "description": "A description covering what you are able to do, how you engage with others and how you feel on a typical day through to on a day when you are unwell or really unwell.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "My wellness", "description": "\n \u003Cdiv\u003E\n \u003Ctable class=\"detail spaced\" width=\"100%\" style=\"background-image: initial; background-position: initial; background-size: initial; background-repeat: initial; background-attachment: initial; background-origin: initial; background-clip: initial; max-width: 100%;\"\u003E\n \u003Ctbody\u003E\n \u003Ctr\u003E\n \u003Ctd colspan=\"3\" rowspan=\"1\" style=\"vertical-align: top;\"\u003E\n \u003Cdiv class=\"xforms-control xforms-output xforms-mediatype-text-html xforms-mediatype-text\" id=\"xf-895≡xf-1189\" style=\"display: inline; zoom: 1;\"\u003E\n \u003Cdiv class=\"xforms-output-output\" id=\"xf-895≡xf-1189≡≡c\" style=\"zoom: 1;\"\u003E\n \u003Cp style=\"margin: 0px 0px 10px;\"\u003EA description covering what you are able to do, how you engage with others and how you feel on a typical day through to on a day when you are unwell or really unwell\u003C/p\u003E\n \u003C/div\u003E\n \u003C/div\u003E\n \u003C/td\u003E\n \u003C/tr\u003E\n \u003C/tbody\u003E\n \u003C/table\u003E\n \u003C/div\u003E \n \u003Ctable class=\"detail spaced\" width=\"100%\" style=\"background-image: initial; background-position: initial; background-size: initial; background-repeat: initial; background-attachment: initial; background-origin: initial; background-clip: initial; font-family: Arial, Helvetica, Geneva, sans-serif; font-size: 12px; max-width: 100%; color: rgb(51, 51, 51);\"\u003E\n \u003Ctbody\u003E\n \u003Ctr\u003E\n \u003Ctd colspan=\"3\" rowspan=\"1\" style=\"vertical-align: top;\"\u003E\n \u003Cdiv class=\"xforms-control xforms-output xforms-mediatype-text-html xforms-mediatype-text\" id=\"xf-895≡xf-1189\" style=\"display: inline; zoom: 1;\"\u003E\n \u003Cdiv class=\"xforms-output-output\" id=\"xf-895≡xf-1189≡≡c\" style=\"zoom: 1;\"\u003E\n \u003Cp style=\"margin: 0px 0px 10px;\"\u003E\n \u003Cul\u003E\n \u003Cli\u003EInclude any causes that might result in you becoming unwell and strategies for avoiding or addressing the causes. For example, not drinking enough water could cause constipation.\u003C/li\u003E\n \u003Cli\u003EInclude any signs that indicate you might be becoming unwell.\u003C/li\u003E\n \u003Cli\u003EOn a bad day describe what is different about what you are able to do, how you engage with others and how you feel.\u003C/li\u003E\n \u003Cli\u003EInclude how your everyday life is affected by any medical conditions e.g. dementia and any symptoms e.g. itchiness, cough, pain and how you manage those conditions.\u003C/li\u003E\n \u003Cli\u003EInclude past health issues or experiences that need to be considered\u003C/li\u003E\n \u003Cli\u003EInclude your wellbeing and lifestyle goals and aspirations\u003C/li\u003E\n \u003C/ul\u003E\n \u003C/p\u003E\n \u003C/div\u003E\n \u003C/div\u003E\n \u003C/td\u003E\n \u003C/tr\u003E\n \u003C/tbody\u003E\n \u003C/table\u003E \n \u003Cul/\u003E \n ", "valueSets": "Free text", "valueDomain": [ { "type": "text" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Please do and please don't", "description": "A description of things you want someone supporting you to do (or not to do). ", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Please do and please don't", "description": "A description of things you want someone supporting you to do (or not to do). \u003Cbr clear=\"none\"/\u003E Things you want someone to \u003Cb\u003Edo \u003C/b\u003E might include (for example): - Talk to me not to my carer, remind me to take my medication, encourage me to wash my hands regularly, explain to me what is happening and why, respond to my communication. \u003Cbr clear=\"none\"/\u003E A description of things you \u003Cb\u003Edo not\u003C/b\u003E want someone supporting you to do might include (for example): - Discussing or asking questions about certain topics, making assumptions about something, providing support when it is not wanted, talking to you in a certain way, undergoing a specific intervention or taking a medication the person does not want.", "valueSets": "Free text", "valueDomain": [ { "type": "text" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "How and when to support me", "description": "A description of how and when you want someone caring for you to support you.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "How and when to support me", "description": "\n \u003Cp\u003EA description of how and when you want someone caring for you to support you.\u003C/p\u003E \n \u003Cp\u003E\n \u003Cul\u003E\n \u003Cli\u003EThis could include support needs in an emergency situation (for example taking blood)\u003C/li\u003E\n \u003Cli\u003EThis could include support you need to maintain important routines or to carry out particular activities, for example: - Personal care routines, Eating and drinking, Bedtime routines, Taking medications, Moving and transitioning\u003C/li\u003E\n \u003Cli\u003EThis could also include support needed with:- wearing glasses/hearing aids/false teeth etc, making informed choices or understanding dangers and risks, managing your emotions, moods and behaviours, memory or confusion.\u003C/li\u003E\n \u003Cli\u003EInclude how your support needs change in different environments. Include any triggers that might result in you needing further support and strategies for avoiding or addressing the triggers. Include how you want the support to be provided.\u003C/li\u003E\n \u003C/ul\u003E\n \u003C/p\u003E \n \u003Cp/\u003E \n ", "valueSets": "Free text", "valueDomain": [ { "type": "text" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Also worth knowing about me", "description": "A description of what is also worth knowing about you for people caring or supporting you. ", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Also worth knowing about me", "description": "\n \u003Cp\u003EA description of what is also worth knowing about you for people caring or supporting you.\u003C/p\u003E \n \u003Cp\u003E\n \u003Cul\u003E\n \u003Cli\u003EThis could include a short history of your life (where you have worked, where you lived, important events in your life, important people in your past life).\u003C/li\u003E\n \u003Cli\u003EThis could include a short profile of your current life:- your work / study, your aspirations, your skills, your networks, things you like e.g. particular foods, places, a football team and things you like to talk about, things you dislike\u003C/li\u003E\n \u003Cli\u003EThis could also include any care and support preferences that have not been included elsewhere.\u003C/li\u003E\n \u003C/ul\u003E\n \u003C/p\u003E \n ", "valueSets": "Free text", "valueDomain": [ { "type": "text" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date", "description": "This is a record of the date that this information was last updated.", "valueSets": "Date and Time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Supported to write this by", "description": "Where relevant, this is a record of name, relationship/role and contact details of the individual who supported the person to write this section e.g. carer, family member, advocate, professional.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Location to multimedia file", "description": "The link to the person's multimedia file", "valueSets": "Link to URL", "valueDomain": [ { "type": "text" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Individual requirements", "implementationGuidance": "This section allows for the sharing of any individual requirements the person may have, such as to support cognitive impairment or mobility issues. This may relate to special needs and would extend to include a record of reasonable adjustments which would be included in ‘Other individual requirements’. \u003Cbr clear=\"none\"/\u003E \n Specific disabilities would be included in the ’Problem list’ section however the requirements to support the disabilities (e.g. needs wheelchair access, needs large print etc.) would be included in this section. \u003Cbr clear=\"none\"/\u003E \n The accessible information requirements information would be the most recent requirement rather than a history of requirements. \u003Cbr clear=\"none\"/\u003E \n ", "description": "The individual requirements of the person.", "concept": [ { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Reasonable adjustment", "description": "A record of reasonable adjustments that must be provided by the service to comply with the Equality Act 2010.", "concept": [ { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Reasonable adjustment record entry", "description": "This is a reasonable adjustment record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items", "concept": [ { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Location", "description": "The location where the reasonable adjustment was identified.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for location.", "valueSets": "NHS Data dictionary : - \u003Ca class=\"\" href=\"https://www.datadictionary.nhs.uk/data_dictionary/nhs_business_definitions/o/organisation_data_service_de.asp?shownav=1\" target=\"\" title=\"\" style=\"\"\u003EOrganisation data service code\u003C/a\u003E \n ", "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": "Reasonable adjustment flag", "description": "\n \u003Cp\u003EUnder the \u003Ca tabindex=\"-1\" class=\"\" aria-disabled=\"false\" title=\"https://www.gov.uk/guidance/equality-act-2010-guidance\" href=\"https://www.gov.uk/guidance/equality-act-2010-guidance\" rel=\"noopener noreferrer\" target=\"_blank\"\u003EEquality Act 2010\u003C/a\u003E, organisations have a legal duty to make changes in their approach or provision to ensure that services are as accessible to people with disabilities as they are for everybody else. These changes are called reasonable adjustments.\u003C/p\u003E \n \u003Cp\u003EReasonable adjustments can mean alterations to buildings by providing lifts, wide doors, ramps and tactile signage, but may also mean changes to policies, procedures and staff training to ensure that services work equally well for people with physical or sensory disabilities, learning disabilities or long-term conditions such as dementia.\u003C/p\u003E \n \u003Cp\u003EOther adjustments include longer appointments, providing easy read materials or communications via a carer. This legal duty is anticipatory which means a service should know about a person’s need for adjustments when they are referred or present for care. For this to happen, and for optimum care to be delivered, adjustments need to be recorded and shared across the NHS.\u003C/p\u003E \n ", "valueSets": "SNOMED CT: - 1108111000000107 |Requires reasonable adjustments for health and care access (Equality Act 2010) (finding)|", "valueDomain": [ { "type": "boolean" } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Reasonable adjustment", "description": "The reasonable adjustment required e.g. requires specific contact method, requires communication professional", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for reasonable adjustment", "valueSets": "SNOMED CT : - Accessible information standard \u003Cbr clear=\"none\"/\u003E ^999002121000000109 |Accessible information - communication support simple reference set (foundation metadata concept)| \u003Cbr clear=\"none\"/\u003E ^999002151000000104 |Accessible information - requires communication professional simple reference set (foundation metadata concept)| \u003Cbr clear=\"none\"/\u003E ^999002131000000106 |Accessible information - requires specific contact method simple reference set (foundation metadata concept)| \u003Cbr clear=\"none\"/\u003E ^999002141000000102 |Accessible information - requires specific information format simple reference set (foundation metadata concept)| \u003Cbr clear=\"none\"/\u003E Refsets for other categories in development" }, { "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": "Reasonable adjustment additional detail", "description": "Further detail about the support required and the consequence of not providing it.", "valueSets": "Free text", "valueDomain": [ { "type": "string" } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date", "description": "The date the reasonable adjustment was identified.", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Performing professional", "description": "The professional who confirmed the need for the reasonable adjustment.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the professional.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The role the professional has in relation to the person.", "valueSets": "FHIR value set : - \u003Ca class=\"\" href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003Esdsjobrole\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the professional.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Speciality", "description": "The specialty of the professional.", "valueSets": "NHS data dictionary - \u003Ca href=\"https://www.datadictionary.nhs.uk/data_dictionary/attributes/m/main_specialty_code_de.asp?shownav=1?query=%22MAIN+SPECIALTY+CODE%22&rank=100&shownav=1\" target=\"\" title=\"\"\u003EMain specialty code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The name of the organisation the professional works for." }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the professional", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK phone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person completing record", "description": "A record of the details of the person that entered the reasonable adjustment and the date on which it was entered.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The organisational role of the person completing record.", "valueSets": "FHIR value set :- \u003Ca href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobrole\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Specialty", "description": "The main specialty of the person completing the record.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The organisation the person completing the record works for.", "valueSets": "\n \u003Cspan style=\"color: rgb(51, 51, 51); font-family: Arial, Helvetica, Geneva, sans-serif; font-size: 12px;\"\u003ENHS data dictionary : - \u003C/span\u003E \n \u003Ca href=\"https://www.datadictionary.nhs.uk/supporting_information/organisation_data_service.html\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date completed", "description": "The date and time the record was completed.", "valueSets": "Date and time.", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the person completing the record. \u003Cbr clear=\"none\"/\u003E \n ", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK telephone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Impairment", "description": "A record of any impairments for the person relating to reasonable adjustments.", "concept": [ { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Impairment record entry", "description": "This is an impairment record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items", "concept": [ { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Location", "description": "The location where the impairment was identified.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for location.", "valueSets": "NHS data dictionary: - \u003Ca class=\"\" href=\"https://www.datadictionary.nhs.uk/data_dictionary/nhs_business_definitions/o/organisation_data_service_de.asp?shownav=1#:~:text=The%20Organisation%20Data%20Service%20(ODS)%20is%20provided%20by%20NHS%20Digital.&text=Health%20and%20Social%20Care%20Organisation,associated%20data%20and%20supporting%20products.\" target=\"\" title=\"\"\u003EOrganisation code service\u003C/a\u003E \n ", "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": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Impairment category", "description": "\n \u003Cdiv\u003EThe category of the impairment e.g. Autism, Dementia, Physical disability, Sensory disability - such as sight or hearing, Long-term condition\u003C/div\u003E \n ", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for impairment.", "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": "Impairment additional detail", "description": "\n \u003Cdiv\u003E\n \u003Cbr clear=\"none\"/\u003EDescription of what the person can do with the impairment, what they want to be able to do and how they should be supported to do it and what the consequences are of not providing the support.\u003C/div\u003E \n \u003Cdiv/\u003E \n \u003Cdiv\u003EWhere there is a sensory disability include sensory processing difficulties (e.g. affects to balance and movement, oversensitive, under-sensitive).\u003C/div\u003E \n ", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date", "description": "The date the impairment was identified.", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Performing professional", "description": "The professional who confirmed the impairment.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the professional.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc", "valueSets": "FHIR value set :- \u003Ca class=\"\" href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobroletype\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the professional.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Speciality", "description": "The specialty of the professional e.g. physiotherapy, oncology, mental health etc", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The name of the organisation the professional works for." }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the professional", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK phone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person completing record", "description": "\n \u003Cbr clear=\"none\"/\u003E A record of the details of the person that entered the impairment and the date on which it was entered.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The organisational role of the person completing record.", "valueSets": "FHIR value set :- \u003Ca href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobrole\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Specialty", "description": "The main specialty of the person completing the record.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The organisation the person completing the record works for.", "valueSets": "\n \u003Cspan style=\"color: rgb(51, 51, 51); font-family: Arial, Helvetica, Geneva, sans-serif; font-size: 12px;\"\u003ENHS data dictionary : - \u003C/span\u003E \n \u003Ca href=\"https://www.datadictionary.nhs.uk/supporting_information/organisation_data_service.html\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date completed", "description": "The date and time the record was completed.", "valueSets": "Date and time.", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the person completing the record. \u003Cbr clear=\"none\"/\u003E \n ", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK telephone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Cognition", "description": "Details of the persons cognitive impairment.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date", "description": "The date when the cognitive impairment was identified.", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Location", "description": "The location where the cognitive impairment was identified.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for location.", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://www.datadictionary.nhs.uk/data_dictionary/nhs_business_definitions/o/organisation_data_service_de.asp?shownav=1#:~:text=The%20Organisation%20Data%20Service%20(ODS)%20is%20provided%20by%20NHS%20Digital.&text=Health%20and%20Social%20Care%20Organisation,associated%20data%20and%20supporting%20products.\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n ", "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": "Cognition", "description": "The cognitive impairment to be considered when communicating with the person, child or their primary carer.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Performing professional", "description": "The professional who identified the cognitive impairment.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the professional.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc", "valueSets": "FHIR value set :- \u003Ca class=\"\" href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobroletype\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the professional.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Speciality", "description": "The specialty of the professional e.g. physiotherapy, oncology, mental health etc", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The name of the organisation the professional works for." }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Contact details", "description": "Contact details of the professional", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK phone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person completing record", "description": "Details of the person completing the record.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The organisational role of the person completing record.", "valueSets": "FHIR value set :- \u003Ca href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobrole\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Specialty", "description": "The main specialty of the person completing the record.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The organisation the person completing the record works for.", "valueSets": "\n \u003Cspan style=\"color: rgb(51, 51, 51); font-family: Arial, Helvetica, Geneva, sans-serif; font-size: 12px;\"\u003ENHS data dictionary : - \u003C/span\u003E \n \u003Ca href=\"https://www.datadictionary.nhs.uk/supporting_information/organisation_data_service.html\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date completed", "description": "The date and time the record was completed.", "valueSets": "Date and time.", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Contact details", "description": "Contact details of the person completing the record. \u003Cbr clear=\"none\"/\u003E \n ", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK telephone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Mobility", "description": "Details of the person's mobility needs.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date", "description": "The date when the mobility needs were identified.", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Location", "description": "The location where the mobility needs were identified.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for location.", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://www.datadictionary.nhs.uk/data_dictionary/nhs_business_definitions/o/organisation_data_service_de.asp?shownav=1#:~:text=The%20Organisation%20Data%20Service%20(ODS)%20is%20provided%20by%20NHS%20Digital.&text=Health%20and%20Social%20Care%20Organisation,associated%20data%20and%20supporting%20products.\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n ", "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 coded text available", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Mobility needs", "description": "The mobility needs of the person that allows movement between two spaces and achieves participation and a degree of independence.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for mobility needs", "valueSets": "SNOMED CT: - ^999002551000000108 |Mobility findings 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": "Performing professional", "description": "The professional who identified the mobility needs.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the professional.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc", "valueSets": "FHIR value set :- \u003Ca class=\"\" href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobroletype\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the professional.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Speciality", "description": "The specialty of the professional e.g. physiotherapy, oncology, mental health etc", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The name of the organisation the professional works for." }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Contact details", "description": "Contact details of the professional", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK phone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person completing record", "description": "Details of the person completing the record.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The organisational role of the person completing record.", "valueSets": "FHIR value set :- \u003Ca href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobrole\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Specialty", "description": "The main specialty of the person completing the record.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The organisation the person completing the record works for.", "valueSets": "\n \u003Cspan style=\"color: rgb(51, 51, 51); font-family: Arial, Helvetica, Geneva, sans-serif; font-size: 12px;\"\u003ENHS data dictionary : - \u003C/span\u003E \n \u003Ca href=\"https://www.datadictionary.nhs.uk/supporting_information/organisation_data_service.html\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date completed", "description": "The date and time the record was completed.", "valueSets": "Date and time.", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Contact details", "description": "Contact details of the person completing the record. \u003Cbr clear=\"none\"/\u003E \n ", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK telephone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Other individual requirements", "description": "Details of any other individual requirements the person may have", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date", "description": "The date when the other individual requirements were identified.", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMD" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Location", "description": "The location where the other individual requirements were identified.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for location.", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://www.datadictionary.nhs.uk/data_dictionary/nhs_business_definitions/o/organisation_data_service_de.asp?shownav=1#:~:text=The%20Organisation%20Data%20Service%20(ODS)%20is%20provided%20by%20NHS%20Digital.&text=Health%20and%20Social%20Care%20Organisation,associated%20data%20and%20supporting%20products.\" target=\"\" title=\"\"\u003EOrganisation service code\u003C/a\u003E \n ", "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 coded text available", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Other individual requirement", "description": "Other individual requirements that a person may have.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Performing professional", "description": "The professional who identified the other individual requirements.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the professional.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc", "valueSets": "FHIR value set :- \u003Ca class=\"\" href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobroletype\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the professional.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Speciality", "description": "The specialty of the professional e.g. physiotherapy, oncology, mental health etc", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The name of the organisation the professional works for." }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Contact details", "description": "Contact details of the professional", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK phone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person completing record", "description": "Details of the person completing the record.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The organisational role of the person completing record.", "valueSets": "FHIR value set :- \u003Ca href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobrole\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Specialty", "description": "The main specialty of the person completing the record.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The organisation the person completing the record works for.", "valueSets": "\n \u003Cspan style=\"color: rgb(51, 51, 51); font-family: Arial, Helvetica, Geneva, sans-serif; font-size: 12px;\"\u003ENHS data dictionary : - \u003C/span\u003E \n \u003Ca href=\"https://www.datadictionary.nhs.uk/supporting_information/organisation_data_service.html\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date completed", "description": "The date and time the record was completed.", "valueSets": "Date and time.", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Contact details", "description": "Contact details of the person completing the record. \u003Cbr clear=\"none\"/\u003E \n ", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK telephone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Alerts", "implementationGuidance": "This section allows for the sharing of alerts. It is unlikely that all alerts generated for a person would be shared as part of the core information standard as some alerts are dynamically generated in local systems, for example within decision support systems. \u003Cbr clear=\"none\"/\u003E \n The alerts that are shared as part of the core information standard should be determined locally. They might, for example, include the presence of a medical implant or MRSA diagnosis, the fact that the person has a dangerous dog or that a person requires reasonable adjustments. \u003Cbr clear=\"none\"/\u003E \n It is important that alerts are managed and removed when they are no longer relevant – e.g. “the dangerous dog” alert if the dog is no longer present. \u003Cbr clear=\"none\"/\u003E \n The alerts displayed to users viewing the core information may vary by use case and user’s role. \u003Cbr clear=\"none\"/\u003E \n ", "description": "Details of alerts.", "concept": [ { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "name": "Alerts record entry", "description": "This is an alerts record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Alert", "description": "Any significant information meriting a specific and highly visible warning to any user (e.g. metallic implant, potential dangerous pet).", "valueSets": "Free text", "valueDomain": [ { "type": "string" } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person completing record", "description": "Details of the person completing the record.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The organisational role of the person completing record.", "valueSets": "FHIR value set :- \u003Ca href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobrole\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Specialty", "description": "The main specialty of the person completing the record.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The organisation the person completing the record works for.", "valueSets": "\n \u003Cspan style=\"color: rgb(51, 51, 51); font-family: Arial, Helvetica, Geneva, sans-serif; font-size: 12px;\"\u003ENHS data dictionary : - \u003C/span\u003E \n \u003Ca href=\"https://www.datadictionary.nhs.uk/supporting_information/organisation_data_service.html\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date completed", "description": "The date and time the record was completed.", "valueSets": "Date and time.", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the person completing the record. \u003Cbr clear=\"none\"/\u003E \n ", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK telephone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Legal information", "implementationGuidance": "This section identifies where there is legal or formal documentation relating to the care of the person. This includes Lasting Power of Attorney (LPA), Advance Decision to Refuse Treatment (ADRT), Mental Capacity Assessments (MCAs) and Mental Health Act (MHA) status. The documentation may be available centrally as part of shared care records or held locally as part of the persons health and care records. NB: Advance statement element is found in the End of life care section. \u003Cbr clear=\"none\"/\u003E \n •Systems should allow copies of legal documentation to be attached to the record where it would be necessary to see copies of the original documents. \u003Cbr clear=\"none\"/\u003E \n •Mental capacity assessment \u003Cbr clear=\"none\"/\u003E \n Mental capacity needs to be assessed at each moment where treatment decisions need to be made. Hence there should be provisions for more than one MCA to be recorded.\u003Cbr clear=\"none\"/\u003E \n •Mental Capacity Act 2005 (England and Wales)\u003Cbr clear=\"none\"/\u003E \n •Adults with Incapacity Act 2000 (Scotland) \u003Cbr clear=\"none\"/\u003E \n •Mental Capacity Act 2016 (Northern Ireland). \u003Cbr clear=\"none\"/\u003E \n If there is a need to communicate the outcome of a mental capacity assessment it is important to record to which specific decision it relates. \u003Cbr clear=\"none\"/\u003E \n •Lasting power of attorney (LPA) should include details of one or more people who have been given power by the person when they had capacity to make decisions about their health and welfare should they lose capacity to make those decisions. To be valid, an LPA must have been registered with the Court of Protection. If life- sustaining treatment is being considered the LPA document must state specifically that the attorney has been given power to consent to or refuse life-sustaining treatment. \u003Cbr clear=\"none\"/\u003E \n •A clinician should satisfy themselves that the Advance Decision to Refuse Treatment (ADRT) is valid and that the circumstances that they are dealing with are those envisaged when the person made the ADRT. A valid and applicable ADRT is legally binding. The record should include the location of the legal document. \u003Cbr clear=\"none\"/\u003E \n ", "description": "The legal information relating to the person.", "concept": [ { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Consent for information sharing", "description": "Details of the person's consent for information sharing", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date", "description": "The date when the consent was given", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Location", "description": "The location where the consent was taken.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for location.", "valueSets": "NHS data dictionary : - \u003Ca class=\"\" href=\"https://www.datadictionary.nhs.uk/data_dictionary/nhs_business_definitions/o/organisation_data_service_de.asp?shownav=1\" target=\"\" title=\"\"\u003EOrganisation data service code\u003C/a\u003E \n ", "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": "Consent for information sharing", "description": "This is a record of consent for information sharing under the common law duty of confidentiality. Where consent has not been obtained or sought, the reason why should be provided. Include best interests decision where person lacks capacity. This is a placeholder until the national guidance is published.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Reason for consent not given", "description": "Reason not given for consent", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Performing professional", "description": "The professional who took the consent for information sharing", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the professional.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc", "valueSets": "FHIR value set :- \u003Ca class=\"\" href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobroletype\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the professional.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Speciality", "description": "The specialty of the professional e.g. physiotherapy, oncology, mental health etc", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The name of the organisation the professional works for." }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the professional", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK phone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person completing record", "description": "Details of the person completing the record.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The organisational role of the person completing record.", "valueSets": "FHIR value set :- \u003Ca href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobrole\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Specialty", "description": "The main specialty of the person completing the record.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The organisation the person completing the record works for.", "valueSets": "\n \u003Cspan style=\"color: rgb(51, 51, 51); font-family: Arial, Helvetica, Geneva, sans-serif; font-size: 12px;\"\u003ENHS data dictionary : - \u003C/span\u003E \n \u003Ca href=\"https://www.datadictionary.nhs.uk/supporting_information/organisation_data_service.html\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date completed", "description": "The date and time the record was completed.", "valueSets": "Date and time.", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the person completing the record. \u003Cbr clear=\"none\"/\u003E \n ", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK telephone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Consent relating to child", "description": "Details of the person's consent relating to child", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date", "description": "The date when the person with responsibility for the child was identified.", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Location", "description": "The location where the person with responsibility for the child was identified.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for location", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://www.datadictionary.nhs.uk/data_dictionary/attributes/o/org/organisation_code_de.asp?shownav=1\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n ", "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 coded text available", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Consent relating to child", "description": "The person with parental responsibility or appointed guardian where a child lacks competency. Consideration of age and competency, applying Gillick competency or Fraser guidelines.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Performing professional", "description": "The professional who identified the person responsible for the child.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the professional.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc", "valueSets": "FHIR value set :- \u003Ca class=\"\" href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobroletype\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the professional.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Speciality", "description": "The specialty of the professional e.g. physiotherapy, oncology, mental health etc", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The name of the organisation the professional works for." }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the professional", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK phone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person completing record", "description": "Details of the person completing the record.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The organisational role of the person completing record.", "valueSets": "FHIR value set :- \u003Ca href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobrole\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Specialty", "description": "The main specialty of the person completing the record.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The organisation the person completing the record works for.", "valueSets": "\n \u003Cspan style=\"color: rgb(51, 51, 51); font-family: Arial, Helvetica, Geneva, sans-serif; font-size: 12px;\"\u003ENHS data dictionary : - \u003C/span\u003E \n \u003Ca href=\"https://www.datadictionary.nhs.uk/supporting_information/organisation_data_service.html\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date completed", "description": "The date and time the record was completed.", "valueSets": "Date and time.", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the person completing the record. \u003Cbr clear=\"none\"/\u003E \n ", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK telephone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Mental capacity assessment", "description": "Details of the persons mental capacity assessment", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date", "description": "The date when the mental capacity assessment was made.", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Location", "description": "The location where the mental capacity assessment was made.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for location", "valueSets": "\n \u003Cdiv\u003ENHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/attributes/organisation_code.html\" target=\"\" title=\"\"\u003EOrganisation code\u003C/a\u003E\n \u003Cbr clear=\"none\"/\u003E\n \u003C/div\u003E \n ", "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": "Mental capacity assessment", "description": "Whether an assessment of the mental capacity of the (adult) person has been undertaken, if so, what capacity the decision relates to and the outcome of the assessment. Also record best interests decision if person lacks capacity.", "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 mental capacity assessment information.", "valueSets": "Free text or URL", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Performing professional", "description": "The professional who made the mental capacity assessment.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the professional.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc", "valueSets": "FHIR value set :- \u003Ca class=\"\" href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobroletype\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the professional.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Speciality", "description": "The specialty of the professional e.g. physiotherapy, oncology, mental health etc", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The name of the organisation the professional works for.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for location", "valueSets": "NHS data dictionary: - \u003Ca href=\"https://www.datadictionary.nhs.uk/data_dictionary/attributes/o/org/organisation_code_de.asp?shownav=1\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "minLength": "3", "maxLength": "7" } ] } ] }, { "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": "Contact details of the professional", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK phone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person completing record", "description": "Details of the person completing the record.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The organisational role of the person completing record.", "valueSets": "FHIR value set :- \u003Ca href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobrole\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Specialty", "description": "The main specialty of the person completing the record.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The organisation the person completing the record works for.", "valueSets": "\n \u003Cspan style=\"color: rgb(51, 51, 51); font-family: Arial, Helvetica, Geneva, sans-serif; font-size: 12px;\"\u003ENHS data dictionary : - \u003C/span\u003E \n \u003Ca href=\"https://www.datadictionary.nhs.uk/supporting_information/organisation_data_service.html\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n ", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for location", "valueSets": "NHS data dictionary : - \u003Ca class=\"\" href=\"https://www.datadictionary.nhs.uk/data_dictionary/attributes/o/org/organisation_code_de.asp?shownav=1\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "minLength": "3", "maxLength": "7" } ] } ] }, { "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": "Professional identifier", "description": "Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date completed", "description": "The date and time the record was completed.", "valueSets": "Date and time.", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the person completing the record. \u003Cbr clear=\"none\"/\u003E \n ", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK telephone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Lasting power of attorney for health and welfare or court-appointed deputy (or equivalent)", "description": "Details of the person's LPA record or equivalent", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date", "description": "The date the LPA was recorded", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Location", "description": "The location where the LPA was given", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for location", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/attributes/organisation_code.html\" target=\"\" title=\"\"\u003EOrganisation code\u003C/a\u003E \n \u003Cbr clear=\"none\"/\u003E \n \u003Cbr clear=\"none\"/\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "minLength": "3", "maxLength": "9" } ] } ] }, { "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": "Lasting power of attorney for health and welfare or court appointed deputy (or equivalent)", "description": "Record of one or more people who have been given power (LPA) by the person when they had capacity to make decisions about their health and welfare should they lose capacity to make those decisions. To be valid, an LPA must have been registered with the Court of Protection. If life-sustaining treatment is being considered the LPA document must state specifically that the attorney has been given power to consent to or refuse life-sustaining treatment. Details of any person (deputy) appointed by the court to make decisions about the person’s health and welfare. A deputy does not have the power to refuse life-sustaining treatment.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for the LPA", "valueSets": "SNOMED CT: - ^999001951000000107 |Personal welfare lasting power of attorney findings simple reference set (foundation metadata concept)|" }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Location of document", "description": "The location of the LPA information", "valueSets": "Free text or URL", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name of LPA", "description": "The names of any appointed people or deputies", "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 LPA", "valueSets": "NHS data dictionary:- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK telephone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Performing professional", "description": "The professional who took the details of the LPA or equivalent", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the professional.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc", "valueSets": "FHIR value set :- \u003Ca class=\"\" href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobroletype\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the professional.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Speciality", "description": "The specialty of the professional e.g. physiotherapy, oncology, mental health etc", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The name of the organisation the professional works for." }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the professional", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK phone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person completing record", "description": "Details of the person who took the LPA.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The organisational role of the person completing record.", "valueSets": "FHIR value set :- \u003Ca href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobrole\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Specialty", "description": "The main specialty of the person completing the record.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The organisation the person completing the record works for.", "valueSets": "\n \u003Cspan style=\"color: rgb(51, 51, 51); font-family: Arial, Helvetica, Geneva, sans-serif; font-size: 12px;\"\u003ENHS data dictionary : - \u003C/span\u003E \n \u003Ca href=\"https://www.datadictionary.nhs.uk/supporting_information/organisation_data_service.html\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date completed", "description": "The date and time the record was completed.", "valueSets": "Date and time.", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the person completing the record. \u003Cbr clear=\"none\"/\u003E \n ", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK telephone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Deprivation of Liberty Safeguards or equivalent", "description": "Details of the person's Deprivation of Liberty Safeguards (DoLS) or equivalent", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Application date", "description": "The date the application was made", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Application status", "description": "The status of the DOLs application.", "valueSets": "Free text : - Requested or authorised", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "10" } ], "example": [ { "type": "valid", "#text": "Requested" }, { "type": "valid", "#text": "Authorised" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Deprivation of liberty safeguards or equivalent", "description": "Record of Deprivation of Liberty Safeguards (DoLS) or equivalent, including the reason for this.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Start date of authorisation", "description": "The date the DOLs was authorised.", "valueSets": "Data and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Planned or actual end date of authorisation", "description": "The planned or actual end date of authorisation.", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Performing professional", "description": "The professional who applied for the DOLs.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the professional.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc", "valueSets": "FHIR value set :- \u003Ca class=\"\" href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobroletype\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the professional.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Speciality", "description": "The specialty of the professional e.g. physiotherapy, oncology, mental health etc", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The name of the organisation the professional works for." }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the professional", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK phone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Mental health act or equivalent status", "description": "Details of the persons mental health act record", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Section start date", "description": "The date the person was detained.", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Section end date", "description": "The date the person was no longer detained.", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Location", "description": "The location where the decision to detain the person was made under the mental health act.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for location", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/attributes/organisation_code.html\" target=\"\" title=\"\"\u003EOrganisation code\u003C/a\u003E \n \u003Cbr clear=\"none\"/\u003E \n \u003Cbr clear=\"none\"/\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "minLength": "3", "maxLength": "9" } ] } ] }, { "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": "Mental health act or equivalent status", "description": "Record where a person diagnosed with a mental disorder is formally detained under the Mental health act or equivalent, including the section number. If person subject to Community Treatment Order or Conditional Discharge (or equivalent) record here.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for mental health act", "valueSets": "NHS data dictionary: - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/mental_health_act_legal_status_classification_code.html\" target=\"\" title=\"\"\u003EMental health act legal status classification code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "2" } ], "example": [ { "type": "valid", "#text": "Formally detained under Mental Health Act Section 2" } ] } ] }, { "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": "Supporting information", "description": "If person subject to Community Treatment Order or Conditional Discharge (or equivalent) record here.", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://www.datadictionary.nhs.uk/supporting_information/community_treatment_order.html\" target=\"\" title=\"\"\u003ECommunity treatment order\u003C/a\u003E \n ", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Performing professional", "description": "The professional who made the decision to detain the person under the mental health act.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the professional.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc", "valueSets": "FHIR value set :- \u003Ca class=\"\" href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobroletype\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the professional.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Speciality", "description": "The specialty of the professional e.g. physiotherapy, oncology, mental health etc", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The name of the organisation the professional works for." }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the professional", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK phone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person completing record", "description": "Details of the person completing the record.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The organisational role of the person completing record.", "valueSets": "FHIR value set :- \u003Ca href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobrole\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Specialty", "description": "The main specialty of the person completing the record.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The organisation the person completing the record works for.", "valueSets": "\n \u003Cspan style=\"color: rgb(51, 51, 51); font-family: Arial, Helvetica, Geneva, sans-serif; font-size: 12px;\"\u003ENHS data dictionary : - \u003C/span\u003E \n \u003Ca href=\"https://www.datadictionary.nhs.uk/supporting_information/organisation_data_service.html\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date completed", "description": "The date and time the record was completed.", "valueSets": "Date and time.", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the person completing the record. \u003Cbr clear=\"none\"/\u003E \n ", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK telephone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Advance decision to refuse treatment (ADRT)", "description": "Details of the person's ADRT status.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date", "description": "The date the ADRT was recorded.", "valueSets": "Date", "valueDomain": [ { "type": "date", "property": [ { "timeStampPrecision": "YMD" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Location", "description": "The location where the ADRT was recorded.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value of location", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://www.datadictionary.nhs.uk/data_dictionary/attributes/o/org/organisation_code_de.asp?shownav=1\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n ", "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 coded text available", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Advance decision to refuse treatment", "description": "A record of an advance decision to refuse one or more specific types of future treatment, made by a person who had capacity at the time of recording the decision. The decision only applies when the person no longer has the capacity to consent to or refuse the specific treatment being considered. An ADRT must be in writing, signed and witnessed. If the ADRT is refusing life-sustaining treatment it must state specifically that the treatment is refused even if the person’s life is at risk.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for advance decision to refuse treatment.", "valueSets": "SNOMED CT:- ^ \u003Ca href=\"https://termbrowser.nhs.uk/?perspective=full&conceptId1=999000561000001109&edition=uk-edition&release=&server=https://termbrowser.nhs.uk/sct-browser-api/snomed&langRefset=999001261000000100,999000691000001104\" target=\"\" title=\"\"\u003E999002181000000105\u003C/a\u003E |Advance decision to refuse treatment preference findings 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": "Performing professional", "description": "The professional who recorded the ADRT", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the professional.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc", "valueSets": "FHIR value set :- \u003Ca class=\"\" href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobroletype\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the professional.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Speciality", "description": "The specialty of the professional e.g. physiotherapy, oncology, mental health etc", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The name of the organisation the professional works for." }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the professional", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK phone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person completing record", "description": "Details of the person who recorded the ADRT.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The organisational role of the person completing record.", "valueSets": "FHIR value set :- \u003Ca href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobrole\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Specialty", "description": "The main specialty of the person completing the record.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The organisation the person completing the record works for.", "valueSets": "\n \u003Cspan style=\"color: rgb(51, 51, 51); font-family: Arial, Helvetica, Geneva, sans-serif; font-size: 12px;\"\u003ENHS data dictionary : - \u003C/span\u003E \n \u003Ca href=\"https://www.datadictionary.nhs.uk/supporting_information/organisation_data_service.html\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date completed", "description": "The date and time the record was completed.", "valueSets": "Date and time.", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the person completing the record. \u003Cbr clear=\"none\"/\u003E \n ", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK telephone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Safeguarding", "implementationGuidance": "This 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. \u003Cbr clear=\"none\"/\u003E \n There may be situations where it is not advisable to share information in this section 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. \u003Cbr clear=\"none\"/\u003E \n Access must be controlled to this information as per SCCI1609: Child Protection - Information Sharing. \u003Cbr clear=\"none\"/\u003E \n ", "description": "The safeguarding details of the person.", "concept": [ { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Safeguarding concerns", "description": "Details of safeguarding concerns", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Safeguarding indicator", "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": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Safeguarding concerns date", "description": "The date the safeguarding concerns were identified.", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Safeguarding concerns end date", "description": "The date safeguarding concerns ended.", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Location", "description": "The location where the safeguarding concerns were identified.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value of location", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/attributes/organisation_code.html?hl=organisation%2Ccode\" target=\"\" title=\"\"\u003EOrganisation code\u003C/a\u003E \n \u003Cbr clear=\"none\"/\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "minLength": "3", "maxLength": "9" } ] } ] }, { "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": "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 : - \u003Ca href=\"https://termbrowser.nhs.uk/?perspective=full&conceptId1=999002381000000108&edition=uk-edition&server=https://termbrowser.nhs.uk/sct-browser-api/snomed&langRefset=999001261000000100,999000691000001104\" target=\"\" title=\"\"\u003E^999002381000000108 | Safeguarding issues simple reference set (foundation metadata concept) |\u003C/a\u003E \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": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Performing professional", "description": "The professional who identified the safeguarding concerns.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the professional.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc", "valueSets": "FHIR value set :- \u003Ca class=\"\" href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobroletype\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the professional.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Speciality", "description": "The specialty of the professional e.g. physiotherapy, oncology, mental health etc", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The name of the organisation the professional works for." }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the professional", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK phone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person completing record", "description": "Details of the person completing the record.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The organisational role of the person completing record.", "valueSets": "FHIR value set :- \u003Ca href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobrole\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Specialty", "description": "The main specialty of the person completing the record.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The organisation the person completing the record works for.", "valueSets": "\n \u003Cspan style=\"color: rgb(51, 51, 51); font-family: Arial, Helvetica, Geneva, sans-serif; font-size: 12px;\"\u003ENHS data dictionary : - \u003C/span\u003E \n \u003Ca href=\"https://www.datadictionary.nhs.uk/supporting_information/organisation_data_service.html\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date completed", "description": "The date and time the record was completed.", "valueSets": "Date and time.", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the person completing the record. \u003Cbr clear=\"none\"/\u003E \n ", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK telephone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] }, { "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": "*", "mro": "R", "name": "Looked after child", "description": "Details of the looked after child", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Looked after child start date", "description": "The date the child became a looked after child.", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Looked after child end date", "description": "The date the child ceased to be a looked after child.", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Local authority", "description": "The named local authority.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for local authority", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://www.datadictionary.nhs.uk/data_dictionary/attributes/o/org/organisation_code_de.asp?shownav=1\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n ", "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": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person completing record", "description": "Details of the person completing the record.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The organisational role of the person completing record.", "valueSets": "FHIR value set :- \u003Ca href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobrole\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Specialty", "description": "The main specialty of the person completing the record.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The organisation the person completing the record works for.", "valueSets": "\n \u003Cspan style=\"color: rgb(51, 51, 51); font-family: Arial, Helvetica, Geneva, sans-serif; font-size: 12px;\"\u003ENHS data dictionary : - \u003C/span\u003E \n \u003Ca href=\"https://www.datadictionary.nhs.uk/supporting_information/organisation_data_service.html\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date completed", "description": "The date and time the record was completed.", "valueSets": "Date and time.", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the person completing the record. \u003Cbr clear=\"none\"/\u003E \n ", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK telephone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Child protection plan", "description": "Details of the child protection plan", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Child protection plan start date", "description": "The start date of the child protection plan", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Child protection plan end date", "description": "The end date of the child protection plan", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Local authority", "description": "The named local authority.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for a local authority", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://www.datadictionary.nhs.uk/data_dictionary/attributes/o/org/organisation_code_de.asp?shownav=1\" target=\"\" title=\"\"\u003Eorganisation data service\u003C/a\u003E \n ", "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": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person completing record", "description": "Details of the person completing the record.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The organisational role of the person completing record.", "valueSets": "FHIR value set :- \u003Ca href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobrole\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Specialty", "description": "The main specialty of the person completing the record.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The organisation the person completing the record works for.", "valueSets": "\n \u003Cspan style=\"color: rgb(51, 51, 51); font-family: Arial, Helvetica, Geneva, sans-serif; font-size: 12px;\"\u003ENHS data dictionary : - \u003C/span\u003E \n \u003Ca href=\"https://www.datadictionary.nhs.uk/supporting_information/organisation_data_service.html\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date completed", "description": "The date and time the record was completed.", "valueSets": "Date and time.", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the person completing the record. \u003Cbr clear=\"none\"/\u003E \n ", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK telephone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Unborn child protection plan", "description": "Details of the unborn child protection plan.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Unborn child protection plan start date", "description": "Start date of the unborn child protection plan.", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Unborn child protection plan end date", "description": "End date of the unborn child protection plan.", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Local authority", "description": "The named local authority.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for local authority", "valueSets": "NHS data dictionary: - \u003Ca href=\"https://www.datadictionary.nhs.uk/data_dictionary/attributes/o/org/organisation_code_de.asp?shownav=1\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n ", "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": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person completing record", "description": "Details of the person completing the record.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The organisational role of the person completing record.", "valueSets": "FHIR value set :- \u003Ca href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobrole\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Specialty", "description": "The main specialty of the person completing the record.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The organisation the person completing the record works for.", "valueSets": "\n \u003Cspan style=\"color: rgb(51, 51, 51); font-family: Arial, Helvetica, Geneva, sans-serif; font-size: 12px;\"\u003ENHS data dictionary : - \u003C/span\u003E \n \u003Ca href=\"https://www.datadictionary.nhs.uk/supporting_information/organisation_data_service.html\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date completed", "description": "The date and time the record was completed.", "valueSets": "Date and time.", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the person completing the record. \u003Cbr clear=\"none\"/\u003E \n ", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK telephone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional contacts", "implementationGuidance": "This section includes current and historic details of health and care professionals, teams or organisations involved in the care of the person. Third sector organisations can be included. \u003Cbr clear=\"none\"/\u003E \n The name of the person’s current care coordinator or key worker should be included here. \u003Cbr clear=\"none\"/\u003E \n ", "description": "The details of the person’s professional contacts.", "concept": [ { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Professional contacts record entry", "description": "This is a professional contacts record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the professional with responsibility for the care of the person.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker, key worker, care home manager, care coordinator, LA hospital liaison person, care home contact, hospital clinician, Independent Mental Capacity Advocate (IMCA) etc", "valueSets": "FHIR value set : - \u003Ca href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobrole\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Key worker", "description": "A flag that identifies the personal contact is the key worker assigned to the person.", "valueSets": "Flag : - Yes or No", "valueDomain": [ { "type": "boolean" } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Speciality", "description": "The specialty of the professional e.g. physiotherapy, oncology, mental health etc", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Team", "description": "The name of the team.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "35" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The name of the organisation.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for location", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://www.datadictionary.nhs.uk/data_dictionary/attributes/o/org/organisation_code_de.asp?shownav=1\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n ", "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": "*", "mro": "R", "name": "Contact details", "description": "Contact details of the professional (e.g. telephone number, email address etc.).", "valueSets": "Free text", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Start date", "description": "The start date of the professional relationship with the person.", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "End date", "description": "The end date of the professional relationship with the person.", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Personal contacts", "implementationGuidance": "This section includes the personal contacts (e.g. family, friends, relatives etc.). Comments should be used to share information such as if a particular contact should be called in an emergency etc. \u003Cbr clear=\"none\"/\u003E \n ", "description": "The details of the individual's personal contacts.", "concept": [ { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Personal contacts record entry", "description": "This is personal contacts record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.", "concept": [ { "type": "item", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "M", "name": "Name", "description": "The name of the personal contact.", "valueSets": "Free text", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Relationship", "description": "The relationship the personal contact has to the person, e.g. father, grandmother, family friend etc.", "valueSets": "FHIR value set : - \u003Ca href=\"https://www.hl7.org/fhir/valueset-relatedperson-relationshiptype.html\" target=\"\" title=\"\"\u003ERelated person\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Relationship type", "description": "Additional roles the person performs on behalf of the other (e.g. Carer, Next of Kin, Emergency Contact, Dependent, etc.)", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Contact details", "description": "Contact details of the personal contact (e.g. telephone number, email address etc.)", "valueSets": "Free Text", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Comments", "description": "Notes on the significance of the personal contact to the person.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Participation in research", "implementationGuidance": "This section should be used to flag participation in clinical trials or other research initiatives. \u003Cbr clear=\"none\"/\u003E \n When a person is enrolled on a drug trial or intervention, the GP receives detailed information from the research sponsor, this section only requires the name of the trial / intervention and the identification code. \u003Cbr clear=\"none\"/\u003E \n ", "description": "Participation in research", "concept": [ { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Participation in research record entry", "description": "This is a Participation in research 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.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name of research study", "description": "Name and details of the research study/trial and/or drug/intervention", "valueSets": "Free text or URL", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "250" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Identification code", "description": "Identification code of research study", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/clinical_trial_identifier.html\" target=\"\" title=\"\"\u003EClinical trial identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "20" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person completing record", "description": "Details of the person completing the record.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The organisational role of the person completing record.", "valueSets": "FHIR value set :- \u003Ca href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobrole\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Specialty", "description": "The main specialty of the person completing the record.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The organisation the person completing the record works for.", "valueSets": "\n \u003Cspan style=\"color: rgb(51, 51, 51); font-family: Arial, Helvetica, Geneva, sans-serif; font-size: 12px;\"\u003ENHS data dictionary : - \u003C/span\u003E \n \u003Ca href=\"https://www.datadictionary.nhs.uk/supporting_information/organisation_data_service.html\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date completed", "description": "The date and time the record was completed.", "valueSets": "Date and time.", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the person completing the record. \u003Cbr clear=\"none\"/\u003E \n ", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK telephone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Referral details", "implementationGuidance": "This section includes a record of current and historic referrals. Referral details includes the service a person is being referred from. 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. \u003Cbr clear=\"none\"/\u003E \n ", "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.", "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", "description": "The details of the referrer that is making the referral or the transfer. \u003Cbr clear=\"none\"/\u003E \n \u003Cbr clear=\"none\"/\u003E This could be the person, GP surgery, department, specialty, sub-specialty, educational institution, mental health team, care home etc.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the referrer.", "valueSets": "Free text", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "Role of the referrer.", "valueSets": "FHIR value set : - \u003Ca href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003Esdsjobrole\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the referrer.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Team", "description": "The team or department of the referrer.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Specialty", "description": "The specialty of the referrer.", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Service", "description": "The service of the referrer.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for service", "valueSets": "SNOMED CT: - 1127531000000102 |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 : - \u003Ca href=\"https://www.datadictionary.nhs.uk/data_dictionary/nhs_business_definitions/o/organisation_data_service_de.asp?shownav=1\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n ", "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": "Contact details", "description": "The contact details of the referrer.", "valueSets": "Free text", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Referral method", "description": "The method in which a referral is sent and received. This may be a letter, email, transcript of a telephone conversation, Choose and Book, in person (self-referral) etc.", "valueSets": "Allow National Codes only\n \u003Col\u003E\n \u003Cli\u003EFax\u003C/li\u003E\n \u003Cli\u003EPhone\u003C/li\u003E\n \u003Cli\u003ESecure Messaging\u003C/li\u003E\n \u003Cli\u003ESecure Email\u003C/li\u003E\n \u003Cli\u003ELetter\u003C/li\u003E\n \u003Cli\u003ENHS E-Referral Service\u003C/li\u003E\n \u003Cli\u003ESelf referral\u003C/li\u003E\n \u003C/ol\u003E \n " }, { "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.", "valueSets": "Free text", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for reason for referral", "valueSets": "SNOMED CT :- ^1127581000000103 |Health issues simple reference set|" }, { "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": "Clinical urgency of referral", "description": "The details of the clinical urgency of referral", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Urgency", "description": "This is the priority of a request for services", "valueSets": "NHS data dictionary : - \u003Ca class=\"\" href=\"https://www.datadictionary.nhs.uk/data_dictionary/attributes/p/prio/priority_type_de.asp?shownav=1\" target=\"\" title=\"\"\u003EPRIORITY TYPE\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "1" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Reason for urgency of referral", "description": "The reason for urgency of referral if not routine.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Referral to", "description": "Details of where the referral is to be sent. \u003Cbr clear=\"none\"/\u003E \n \u003Cbr clear=\"none\"/\u003E If not an individual, this could be a service, e.g. GP surgery, department, specialty, subspecialty, educational institution, mental health etc.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "Name of person the referral is to be sent to.", "valueSets": "Free text", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "Role of person where the referral is to be sent to.", "valueSets": "FHIR value set : - \u003Ca href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003Esdsjobrole\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the person where the referral is sent to.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Team", "description": "The team or department of the person where the referral is being sent to", "valueSets": "Free text.", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Specialty", "description": "The specialty the referral is being sent to e.g. physiotherapy, oncology, mental health etc", "valueSets": "NHS data dictionary - \u003Ca\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Service", "description": "The service of where the referral is sent to.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for service", "valueSets": "SNOMED CT: - 1127531000000102 |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 where the referral is to be sent.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for organisation", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://www.datadictionary.nhs.uk/data_dictionary/attributes/o/org/organisation_code_de.asp?shownav=1\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n ", "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": "Contact details", "description": "The contact details of where the referral is to be sent.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Referral criteria", "description": "Records whether specific criteria required for referral, to a particular service, have been met (may be nationally or locally determined). This field is used to outline which criteria have been met where a service has indicated specific criteria and to explain the rationale for referral where criteria have not been met.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Return response to", "description": "Name of professional to be communicated with, if not the referrer", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contacts with professionals", "implementationGuidance": "This section includes the details of the person’s 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’s discipline. This includes outpatient appointments, home visits, hospital and outpatient attendances, out of hours GP visits, clinic appointments, social worker visits etc. \u003Cbr clear=\"none\"/\u003E \n ", "description": "The details of the person’s contact with a professional.", "concept": [ { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "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.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date 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 : - \u003Ca href=\"https://www.datadictionary.nhs.uk/data_dictionary/attributes/o/org/organisation_code_de.asp?shownav=1\" target=\"\" title=\"\"\u003EOrganisation service code\u003C/a\u003E \n ", "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": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Seen by", "description": "The professional that saw the person.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the professional that saw the person", "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 : - \u003Ca href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003Esdsjobrole\u003C/a\u003E \n " } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Responsible professional", "description": "The name and role of the professional that had overall responsibility for the person e.g. consultant, nurse consultant, midwife, allied health professional (may not have actually seen the person).", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the responsible professional.", "valueSets": "Free text", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The role of the responsible professional", "valueSets": "FHIR value set : - \u003Ca href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003Esdsjobrole\u003C/a\u003E \n " } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Location type", "description": "The type of location where the contact took place e.g. person's home", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_location_type_code.html?hl=activity%2Clocation%2Ctype%2Ccode\" target=\"\" title=\"\"\u003EActivity location type code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact type", "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 - \u003Ca class=\"\" href=\"https://www.datadictionary.nhs.uk/data_dictionary/attributes/c/cons/consultation_medium_used_de.asp?shownav=1?query=%22consultation%22&rank=30&shownav=1\" target=\"\" title=\"\"\u003EConsultation medium\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "2" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Specialty", "description": "The specialty e.g. physiotherapy, oncology, mental health etc", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Service", "description": "The service that was provided.", "valueSets": "SNOMED CT :- 1127531000000102 |Services simple reference set (foundation metadata concept)| \u003Cbr clear=\"none\"/\u003E \n \u003Cbr clear=\"none\"/\u003E \n " }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Professionals present", "description": "The name, role of the additional individuals or team members including consultant(s), nurse consultant(s), allied health professional(s), social worker(s)", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the professional present", "valueSets": "Free text", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The role of the professional present.", "valueSets": "FHIR value set : - \u003Ca href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003Esdsjobrole\u003C/a\u003E \n " } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Outcome of contact", "description": "This records the outcome of the contact.", "valueSets": "\n \u003Cdiv\u003ENHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/attended_or_did_not_attend_code.html\" target=\"\" title=\"\"\u003EAttended or did not attend code\u003C/a\u003E\n \u003C/div\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "1" } ] } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Admission details", "implementationGuidance": "This section includes all instances where a person is admitted to an inpatient setting and would include the relevant site code according to the Organisation Data Service (ODS) codes. \u003Cbr clear=\"none\"/\u003E \n ", "description": "Admission details", "concept": [ { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Admission details record entry", "description": "This is the admission details record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.", "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": "Admitted to", "description": "The hospital the person was admitted to.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for admission to", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/organisation_code__code_of_provider_.html?hl=organisation%2Ccode%2Ccode%2Cprovider\" target=\"\" title=\"\"\u003EOrganisations code of provider\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "minLength": "3", "maxLength": "6" } ] } ] }, { "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": "Responsible care professional", "description": "The care professional who has overall responsibility for the person (may not actually see the person)", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the responsible care professional.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The role of the responsible consultant.", "valueSets": "FHIR value set: - \u003Ca href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003Esdsjobrole\u003C/a\u003E \n " } ] }, { "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": "SNOMED CT: - ^1127581000000103 |Health issues simple reference set|" }, { "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": "Admission method", "description": "How the person was admitted to hospital e.g. elective, emergency, maternity, transfer etc.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for admission method", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://www.datadictionary.nhs.uk/data_dictionary/data_field_notes/a/ad/admission_method_code_(hospital_provider_spell)_de.asp?shownav=1\" target=\"\" title=\"\"\u003EAdmission method\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "2" } ] } ] }, { "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": "Legal status on admission", "description": "Whether the person was admitted as informal or formal/detained.", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/mental_health_act_legal_status_classification_code__on_admission_.html\" target=\"\" title=\"\"\u003EMental health act legal status classification code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "2" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Source of admission", "description": "Where the person was immediately prior to admission, e.g. usual place of residence, temporary place of residence, penal establishment.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value of source of admission", "valueSets": "NHS data dictionary :- \u003Ca href=\"http://www.datadictionary.nhs.uk/data_dictionary/attributes/s/smo/source_of_admission_de.asp?shownav=1?query=%22source+of+admission%22&rank=100&shownav=1\" target=\"\" title=\"\"\u003ESource of admission\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "fixed": "an2", "maxLength": "2" } ] } ] }, { "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": "Individual accompanying person", "description": "Details of the accompanying individual and the extent to which they have provided the information about the person.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "Name of individual accompanying person.", "valueSets": "Free text", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "Role of the individual accompanying the person.", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://www.datadictionary.nhs.uk/data_dictionary/attributes/c/card/care_professional_type_de.asp?shownav=1\" target=\"\" title=\"\"\u003ECare professional\u003C/a\u003E \n " }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Relationship", "description": "Relationship of individual accompanying the person.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for relationship to person.", "valueSets": "FHIR value set: - \u003Ca href=\"https://www.hl7.org/fhir/valueset-relatedperson-relationshiptype.html\" target=\"\" title=\"\"/\u003E \n \u003Ca href=\"https://www.hl7.org/fhir/valueset-relatedperson-relationshiptype.html\" target=\"\" title=\"\"\u003ERelationship\u003C/a\u003E type" }, { "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": "Comment", "description": "Information about the extent to which the accompanying individual provided information about the person.", "valueSets": "Free text.", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Specialty", "description": "The specialty e.g. physiotherapy, oncology, mental health etc", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for specialty", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "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", "implementationGuidance": "This section includes the summary details of the person’s discharge, but not the actual discharge content which is shared in the relevant sections such as problem list or procedures. This should include all instances of discharge from a healthcare setting with relevant ODS codes and readable names of the discharging wards or departments of organisations where available. \u003Cbr clear=\"none\"/\u003E \n ", "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.", "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": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Discharge location", "description": "The hospital the person was discharged from.", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://www.datadictionary.nhs.uk/data_dictionary/nhs_business_definitions/o/organisation_data_service_de.asp?shownav=1\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "minLength": "3", "maxLength": "5" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Discharging consultant", "description": "The consultant responsible for the person at time of discharge.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the discharging consultant", "valueSets": "Free text", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The role of the discharging consultant", "valueSets": "FHIR value set : - \u003Ca href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003Esdsjobrole\u003C/a\u003E \n " } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Discharge method", "description": "The method of discharge from hospital e.g. person discharged on clinical advice or with clinical consent; person discharged him/herself or was discharged by a relative or advocate.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for discharge method", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://www.datadictionary.nhs.uk/data_dictionary/attributes/d/disc/discharge_method_de.asp?shownav=1\" target=\"\" title=\"\"\u003EDischarge method\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "1" } ] } ] }, { "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": "Discharging specialty", "description": "The specialty of the consultant responsible for the person at the time of discharge.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for discharge speciality", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "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": "Discharging department", "description": "The department from which the person is discharged.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Legal status on discharge", "description": "Whether the person was discharged as informal or formal/detained.", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/mental_health_act_legal_status_classification_code.html\" target=\"\" title=\"\"\u003EMental health act classification code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "2" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Discharge destination ", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Discharge destination", "description": "The destination of the person on discharge from hospital e.g. usual place of residence, NHS run care home.", "valueSets": "NHS data dictionary - \u003Ca class=\"\" href=\"https://www.datadictionary.nhs.uk/data_dictionary/attributes/d/disc/discharge_destination_de.asp?shownav=1?query=%22discharge+destination%22&rank=100&shownav=1\" target=\"\" title=\"\"\u003EDischarge destination\u003C/a\u003E .", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "2" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Discharge address", "description": "Address to which the person is discharged if not the usual place of residence.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/attributes/address.html\" target=\"\" title=\"\"\u003EAddress\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "minLength": "35", "maxLength": "175" } ] } ] } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Future appointments", "implementationGuidance": "This section includes the details of any future appointments the person may have. This can include both health and care appointments for example a home visit from a domiciliary care worker. \u003Cbr clear=\"none\"/\u003E \n The section includes both specialty and service. Specialty should be used where possible for secondary care appointments, but service can be used for example for social care where specialty doesn’t apply. \u003Cbr clear=\"none\"/\u003E \n ", "description": "Details of future appointments.", "concept": [ { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "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.", "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": "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": "NHS data dictionary : - \u003Ca href=\"https://www.datadictionary.nhs.uk/data_dictionary/attributes/o/org/organisation_code_de.asp?shownav=1\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n ", "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": "Specialty", "description": "The specialty e.g. physiotherapy, oncology, mental health etc.", "valueSets": "\n \u003Cdiv\u003ENHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E\n \u003C/div\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Service", "description": "The service being provided.", "valueSets": "SNOMED CT: - 1127531000000102 |Services simple reference set (foundation metadata concept)|" }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional to see the person", "description": "The name and role of the professional e.g. consultant, care worker, nurse consultant.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the professional seeing the person.", "valueSets": "Free text", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The role of the professional seeing the person.", "valueSets": "FHIR value set : - \u003Ca href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003Esdsjobrole\u003C/a\u003E \n " } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Vaccinations", "implementationGuidance": "This section includes all vaccinations including routine vaccinations of children in accordance with the Public Health England Green Book, as well as any vaccines outside the schedule and those administered abroad. \u003Cbr clear=\"none\"/\u003E \n Information about vaccines should be shared in line with nationally agreed naming and utilisation conventions. \u003Cbr clear=\"none\"/\u003E \n The vaccine manufacturer should be derived from GS1 code. \u003Cbr clear=\"none\"/\u003E \n Sequence number for a vaccination which is given in several separate doses should be shared using SNOMED CT. \u003Cbr clear=\"none\"/\u003E \n If applicable, when sharing Indication for vaccinations given as part of the Green Book either free text or SNOMED CT can be used. Example SNOMED CT is 171279008| Immunisation due (finding). \u003Cbr clear=\"none\"/\u003E \n This section allows for retrospective vaccinations as reported by the person or their guardian or carer, including those given abroad, with a flag to indicate if this is the case. \u003Cbr clear=\"none\"/\u003E \n Vaccinations performed by a third party should include a date or partial date of when the vaccine was administered as well as location (which could include other countries). The attributes of performing professional would allow the organisation that administered the vaccine to be shared, if known. In addition, the ‘Reported’ flag should be set to ‘Yes’ to indicate that the information was reported to the professional by the person. \u003Cbr clear=\"none\"/\u003E \n ", "description": "Details of vaccinations.", "concept": [ { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Vaccinations record entry", "description": "\n \u003Cp/\u003E \n \u003Cp\u003EThis is the vaccinations record entry.\u003C/p\u003E \n \u003Cp/\u003E \n \u003Cp\u003EThere may be 0 to many record entries under a section.\u003C/p\u003E \n \u003Cp/\u003E \n \u003Cp\u003EEach record entry is made up of a number of elements or data items.\u003C/p\u003E \n ", "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": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Location", "description": "The location where the vaccine was administered.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for location", "valueSets": "NHS data dictionary: - \u003Ca href=\"https://www.datadictionary.nhs.uk/data_dictionary/attributes/o/org/organisation_code_de.asp?shownav=1\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n ", "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": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Performing professional", "description": "The professional who administered the vaccine.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the professional.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The role the professional has in relation to the person.", "valueSets": "FHIR value set : - \u003Ca class=\"\" href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003Esdsjobrole\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the professional.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Speciality", "description": "The specialty of the professional.", "valueSets": "NHS data dictionary - \u003Ca href=\"https://www.datadictionary.nhs.uk/data_dictionary/attributes/m/main_specialty_code_de.asp?shownav=1?query=%22MAIN+SPECIALTY+CODE%22&rank=100&shownav=1\" target=\"\" title=\"\"\u003EMain specialty code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The name of the organisation the professional works for." }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the professional", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK phone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] }, { "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", "description": "The coded value for vaccine product.", "valueSets": "dm+d (SNOMED) Concept ID AMP (preferred) or VMP term for the vaccine product \u003Cbr clear=\"none\"/\u003E \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": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Manufacturer", "description": "Name of vaccine manufacturer.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "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 coded value for vaccine procedure", "valueSets": "SNOMED CT :- \u003C 127785005 |Administration of substance to produce immunity, either active or passive (procedure)| or \u003C\u003C 1066171000000108 Seasonal influenza vaccination given by midwife or \u003C\u003C 713404003 Vaccination given (code and all its descendants)" }, { "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": "SNOMED CT : - ^ \u003Ca class=\"\" href=\"https://termbrowser.nhs.uk/?perspective=full&conceptId1=1127941000000100&edition=uk-edition&release=&server=https://termbrowser.nhs.uk/sct-browser-api/snomed&langRefset=999001261000000100,999000691000001104\" target=\"\" title=\"\"\u003E1127941000000100 |Vaccine body site of administration simple reference set (foundation metadata concept)|\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "description": "Free text field to be used if no coded text available", "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": "SNOMED CT: - \u003Ca href=\"https://termbrowser.nhs.uk/?perspective=full&conceptId1=999000051000001100&edition=uk-edition&release=&server=https://termbrowser.nhs.uk/sct-browser-api/snomed&langRefset=999001261000000100,999000691000001104\" target=\"\" title=\"\"\u003E^999000051000001100 |ePrescribing route of administration simple reference set (foundation metadata concept)|\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "description": "Free text field to be used if no coded text available", "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": "SNOMED CT:- ^1127601000000107 | Healthcare matters simple reference set (foundation metadata concept) | \u003Cbr clear=\"none\"/\u003E \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": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Dose amount", "description": "Amount of vaccine administered.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Value", "description": "The amount of vaccine administered", "valueSets": "Free text", "valueDomain": [ { "type": "string" } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Units of measure", "description": "The units of measure for the dose amount", "valueSets": "UCUM code", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "10" } ] } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Dose sequence", "description": "Nominal position in a series of vaccines.", "valueSets": "Numeric value", "valueDomain": [ { "type": "decimal", "property": [ { "maxInclude": "1" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Outcome status", "description": "Whether the vaccine was administered or not, including the reason why", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Not given flag", "description": "Flag to indicate that the vaccination was NOT given at this time by a healthcare professional", "valueSets": "Flag: - Yes or No", "valueDomain": [ { "type": "boolean", "property": [ { "fixed": "3" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Vaccination situation (not given reason)", "description": "The reason why a vaccination was not administered.", "valueSets": "FHIR value set : - \u003Ca href=\"https://simplifier.net/ukcore/valueset-ukcore-reasonimmunizationnotadministered\" target=\"\" title=\"\"\u003EReason code\u003C/a\u003E \n \u003Cbr clear=\"none\"/\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "150" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person completing record", "description": "Details of the person completing the record.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The organisational role of the person completing record.", "valueSets": "FHIR value set :- \u003Ca href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobrole\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Specialty", "description": "The main specialty of the person completing the record.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The organisation the person completing the record works for.", "valueSets": "\n \u003Cspan style=\"color: rgb(51, 51, 51); font-family: Arial, Helvetica, Geneva, sans-serif; font-size: 12px;\"\u003ENHS data dictionary : - \u003C/span\u003E \n \u003Ca href=\"https://www.datadictionary.nhs.uk/supporting_information/organisation_data_service.html\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date completed", "description": "The date and time the record was completed.", "valueSets": "Date and time.", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the person completing the record. \u003Cbr clear=\"none\"/\u003E \n ", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK telephone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Reported", "description": "Details of the vaccination reported to the professional", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date", "description": "The date or partial date that the reported vaccination was given in the opinion of the person.", "valueSets": "Date/time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Reported", "description": "A flag to indicate the information was reported to a professional", "valueSets": "Flag: - Yes or No", "valueDomain": [ { "type": "boolean", "property": [ { "default": "3" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Report origin", "description": "The source of the data when the report of the vaccination event is not based on information from the person who administered the vaccine.", "valueSets": "FHIR value set:- https://www.hl7.org/fhir/valueset-immunization-origin.html", "valueDomain": [ { "type": "string" } ] } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Problem list", "implementationGuidance": "This section allows for all relevant diagnoses, symptoms, \u003Cbr clear=\"none\"/\u003E \n This would include disabilities, including learning disabilities, and conditions such as autism where they fall into the above categories i.e. are diagnosed, seen as a problem by the person or are considered a condition or similar. Behavioural factors which are not formal diagnoses but could be seen as a problem for the person would also appear under this section. \u003Cbr clear=\"none\"/\u003E \n ‘Onset date’ should be included where available even if this is estimated in source systems. \u003Cbr clear=\"none\"/\u003E \n When a diagnosis has not yet been made, the most granular clinical concept with the highest level of certainty should be displayed. This may be a problem, symptom, sign, or test result, and may evolve over time, as a conventional diagnosis is reached. For example, ‘dyspepsia’ may be the diagnosis when a patient first presents with indigestion, upgraded to ‘gastric ulcer’ when this is found at endoscopy, and ‘gastric cancer’ when biopsies reveal this. \u003Cbr clear=\"none\"/\u003E \n Unconfirmed or excluded diagnoses should not be include in structured coded \u003Cbr clear=\"none\"/\u003E \n fields, but may be included in free text in the comments field. Thus, in the example above, gastric ulcer and gastric cancer may be in a list of differential diagnoses at presentation, but the symptom, dyspepsia, should be included in the diagnosis field. The differential diagnoses should only be included in free text in the comments field, and not in a coded diagnosis field until confirmed with confidence. \u003Cbr clear=\"none\"/\u003E \n Co-morbidities’ should be shown as separate diagnoses. For example, dementia may be recorded as a primary diagnosis by a psycho-geriatrician, but as a co- morbidity where a patient is admitted for a hip replacement. Local implementations will need to define what will be prioritised according to each use case. \u003Cbr clear=\"none\"/\u003E \n In some situations a diagnosis may need to be qualified by a number of attributes to give further detail. A generic approach to these attributes (such as grade; severity; distribution; behaviour; laterality etc.) has not yet been agreed. Until this is achieved it is recommended that these features are included as free text comments. \u003Cbr clear=\"none\"/\u003E \n ", "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. \u003Cbr clear=\"none\"/\u003E \n \u003Cbr clear=\"none\"/\u003E There may be 0 to many record entries under problem list. \u003Cbr clear=\"none\"/\u003E \n \u003Cbr clear=\"none\"/\u003E Each record entry is made up of a number of elements or data items.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date", "description": "The date the problem was identified.", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Performing professional", "description": "The professional who identified the problem.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the professional.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc", "valueSets": "FHIR value set :- \u003Ca class=\"\" href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobroletype\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the professional.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Speciality", "description": "The specialty of the professional e.g. physiotherapy, oncology, mental health etc", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The name of the organisation the professional works for." }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the professional", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK phone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Location", "description": "The location the problem was identified.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for location.", "valueSets": "NHS data dictionary : - \u003Ca class=\"\" href=\"https://www.datadictionary.nhs.uk/data_dictionary/nhs_business_definitions/o/organisation_data_service_de.asp?shownav=1\" target=\"\" title=\"\"\u003EOrganisation data service code\u003C/a\u003E \n ", "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": "group", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "M", "name": "Problem", "description": "A condition which needs addressing and so is important for every professional to know about when seeing the person. \u003Cbr clear=\"none\"/\u003E \n \u003Cbr clear=\"none\"/\u003E Problems may include diagnoses, symptoms, disabilities and social or behavioural issues", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for the problem list.", "valueSets": "SNOMED CT : - \u003Ca class=\"\" href=\"https://termbrowser.nhs.uk/?perspective=full&conceptId1=1127581000000103&edition=uk-edition&release=&server=https://termbrowser.nhs.uk/sct-browser-api/snomed&langRefset=999001261000000100,999000691000001104\" target=\"\" title=\"\"\u003E^1127581000000103 |Health issues simple reference set|\u003C/a\u003E \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": "Onset date", "description": "A date or estimated date that the problem began", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "End Date", "description": "The date or estimated date the problem was resolved.", "valueSets": "Date and time.", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Stage of disease", "description": "The stage of the disease where relevant.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person completing record", "description": "Details of the person completing the record.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The organisational role of the person completing record.", "valueSets": "FHIR value set :- \u003Ca href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobrole\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Specialty", "description": "The main specialty of the person completing the record.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The organisation the person completing the record works for.", "valueSets": "\n \u003Cspan style=\"color: rgb(51, 51, 51); font-family: Arial, Helvetica, Geneva, sans-serif; font-size: 12px;\"\u003ENHS data dictionary : - \u003C/span\u003E \n \u003Ca href=\"https://www.datadictionary.nhs.uk/supporting_information/organisation_data_service.html\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date completed", "description": "The date and time the record was completed.", "valueSets": "Date and time.", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the person completing the record. \u003Cbr clear=\"none\"/\u003E \n ", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK telephone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Comment", "description": "Supporting text may be given covering the problem.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Procedures and therapies", "implementationGuidance": "All procedures undertaken should be included in the e-discharge summary, including: \u003Cbr clear=\"none\"/\u003E \n •diagnostic as well as therapeutic procedures and therapies \u003Cbr clear=\"none\"/\u003E \n •medical as well as psychological procedures and therapies (e.g. cognitive behaviour therapy; follow-up interventions as a result of physical health checks) \u003Cbr clear=\"none\"/\u003E \n •procedures carried out on different days during the hospital stay. \u003Cbr clear=\"none\"/\u003E \n • complementary or alternative procedures and therapies \u003Cbr clear=\"none\"/\u003E \n •Outcomes or results of procedures should be recorded in the ‘comments’ field, as well as a comment to clarify such as statement that information is partial or incomplete \u003Cbr clear=\"none\"/\u003E \n •The discharge summary should include the operation which was actually carried out, not the planned procedure, as this may have been changed. The detail should be taken from the record of the actual procedure (e.g. operating note) rather than the planned procedure (e.g. consent to treatment). \u003Cbr clear=\"none\"/\u003E \n •The procedure, anatomical site and laterality should be SNOMED CT coded wherever possible, with free text as an option where this is not possible. \u003Cbr clear=\"none\"/\u003E \n •There are specific elements for complications relating to the procedure and anaesthetic issues \u003Cbr clear=\"none\"/\u003E \n •The anaesthesia issues included could be, for example, “short neck, difficult to intubate” and the actual intubation grade or adverse reactions. \u003Cbr clear=\"none\"/\u003E \n •Clinical coders use discharge summaries for coding hospital episodes. All those deemed to be clinically important for future care should be listed. Thus venesection would not usually merit noting, unless undertaken as a therapeutic procedure for polycythaemia. \u003Cbr clear=\"none\"/\u003E \n •Whilst hospitals use OPCS codes for procedures, these cannot be used by GP practices, so should not be included in discharge summaries. \u003Cbr clear=\"none\"/\u003E \n ", "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", "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.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date", "description": "The date the procedure was performed.", "valueSets": "Date and time.", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Location", "description": "The location where the procedure was undertaken.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for location.", "valueSets": "NHS data dictionary : - \u003Ca class=\"\" href=\"https://www.datadictionary.nhs.uk/data_dictionary/nhs_business_definitions/o/organisation_data_service_de.asp?shownav=1\" target=\"\" title=\"\"\u003EOrganisation data service code\u003C/a\u003E \n ", "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": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Performing professional", "description": "The professional who performed the procedure.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the professional.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc", "valueSets": "FHIR value set :- \u003Ca class=\"\" href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobroletype\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the professional.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Speciality", "description": "The specialty of the professional e.g. physiotherapy, oncology, mental health etc", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The name of the organisation the professional works for." }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the professional", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK phone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "M", "name": "Procedure", "description": "The therapeutic or diagnostic procedure performed. Includes both psychological and medical therapies and procedures (e.g. cognitive\nbehaviour therapy, or follow-up interventions as a result of physical health\nchecks). Complementary or alternative procedures and therapies should be recorded here.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The procedure code.", "valueSets": "SNOMED CT : - << \u003Ca class=\"\" href=\"https://termbrowser.nhs.uk/?perspective=full&conceptId1=71388002&edition=uk-edition&release=&server=https://termbrowser.nhs.uk/sct-browser-api/snomed&langRefset=999001261000000100,999000691000001104\" target=\"\" title=\"\"\u003E71388002\u003C/a\u003E |Procedure| OR << \u003Ca href=\"https://termbrowser.nhs.uk/?perspective=full&conceptId1=129125009&edition=uk-edition&release=&server=https://termbrowser.nhs.uk/sct-browser-api/snomed&langRefset=999001261000000100,999000691000001104\" target=\"\" title=\"\"\u003E129125009\u003C/a\u003E |Procedure with explicit context|" }, { "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": "Anatomical site", "description": "The body site of the procedure", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value of the anatomical site.", "valueSets": "SNOMED CT :- < \u003Ca href=\"https://termbrowser.nhs.uk/?perspective=full&conceptId1=123037004&edition=uk-edition&release=&server=https://termbrowser.nhs.uk/sct-browser-api/snomed&langRefset=999001261000000100,999000691000001104\" target=\"\" title=\"\"\u003E123037004\u003C/a\u003E |Body structure (body structure)|" }, { "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": "Laterality of the procedure", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for laterality.", "valueSets": "SNOMED CT:- < \u003Ca href=\"https://termbrowser.nhs.uk/?perspective=full&conceptId1=182353008&edition=uk-edition&release=&server=https://termbrowser.nhs.uk/sct-browser-api/snomed&langRefset=999001261000000100,999000691000001104\" target=\"\" title=\"\"\u003E182353008\u003C/a\u003E |Side (qualifier value)|" }, { "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": "Complications related to procedure", "description": "Details of any intra-operative complications encountered during the procedure, arising during the person’s stay in the recovery unit or directly attributable to the procedure.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for complications relating to procedure.", "valueSets": "SNOMED CT : - < \u003Ca href=\"https://termbrowser.nhs.uk/?perspective=full&conceptId1=404684003&edition=uk-edition&release=&server=https://termbrowser.nhs.uk/sct-browser-api/snomed&langRefset=999001261000000100,999000691000001104\" target=\"\" title=\"\"\u003E404684003\u003C/a\u003E |Clinical finding (finding)| \u003Cp/\u003E \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": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Specific anesthesia issues", "description": "Details of any adverse reaction to any anesthetic agents including local anesthesia. Problematic intubation, transfusion reaction, etc.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for specific anesthesia 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": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person completing record", "description": "Details of the person completing the record.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The organisational role of the person completing record.", "valueSets": "FHIR value set :- \u003Ca href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobrole\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Specialty", "description": "The main specialty of the person completing the record.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The organisation the person completing the record works for.", "valueSets": "\n \u003Cspan style=\"color: rgb(51, 51, 51); font-family: Arial, Helvetica, Geneva, sans-serif; font-size: 12px;\"\u003ENHS data dictionary : - \u003C/span\u003E \n \u003Ca href=\"https://www.datadictionary.nhs.uk/supporting_information/organisation_data_service.html\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date completed", "description": "The date and time the record was completed.", "valueSets": "Date and time.", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the person completing the record. \u003Cbr clear=\"none\"/\u003E \n ", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK telephone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] }, { "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": "Social context", "implementationGuidance": "This section includes information about the social setting in which the person lives, such as their household, occupational, and lifestyle factors. Social circumstances includes the person’s social background, network and personal circumstances, e.g. housing, and should also include if the person is a carer. ‘Smoking status’ should be shared using SNOMED CT rather than yes or no. \u003Cbr clear=\"none\"/\u003E \n ", "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": "Household composition", "description": "Details of the person's household composition.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date", "description": "The date when the household composition was taken.", "valueSets": "Date and time.", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Location", "description": "The location where the household composition was taken.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for location.", "valueSets": "NHS data dictionary : - \u003Ca class=\"\" href=\"https://www.datadictionary.nhs.uk/data_dictionary/nhs_business_definitions/o/organisation_data_service_de.asp?shownav=1\" target=\"\" title=\"\"\u003EOrganisation data service code\u003C/a\u003E \n ", "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": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Household composition", "description": "Description of the household composition e.g. lives alone, lives with family, lives with partner, etc.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value of household composition", "valueSets": "SNOMED CT: - 1027891000000106 | Household composition findings 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": "Performing professional", "description": "The professional who took the household composition.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the professional.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc", "valueSets": "FHIR value set :- \u003Ca class=\"\" href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobroletype\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the professional.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Speciality", "description": "The specialty of the professional e.g. physiotherapy, oncology, mental health etc", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The name of the organisation the professional works for." }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the professional", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK phone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person completing record", "description": "Details of the person completing the record.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The organisational role of the person completing record.", "valueSets": "FHIR value set :- \u003Ca href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobrole\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Specialty", "description": "The main specialty of the person completing the record.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The organisation the person completing the record works for.", "valueSets": "\n \u003Cspan style=\"color: rgb(51, 51, 51); font-family: Arial, Helvetica, Geneva, sans-serif; font-size: 12px;\"\u003ENHS data dictionary : - \u003C/span\u003E \n \u003Ca href=\"https://www.datadictionary.nhs.uk/supporting_information/organisation_data_service.html\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date completed", "description": "The date and time the record was completed.", "valueSets": "Date and time.", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the person completing the record. \u003Cbr clear=\"none\"/\u003E \n ", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK telephone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Occupational history", "description": "The current and/or previous occupation(s) of the person.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date", "description": "The date when the occupational history was taken.", "valueSets": "Date and time.", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Location", "description": "The location where the occupational history was taken.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for the location.", "valueSets": "NHS Data dictionary : - \u003Ca class=\"\" href=\"https://www.datadictionary.nhs.uk/data_dictionary/nhs_business_definitions/o/organisation_data_service_de.asp?shownav=1\" target=\"\" title=\"\"\u003EOrganisation data service code\u003C/a\u003E \n ", "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": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Occupational history", "description": "The current and/or previous occupation(s) of the person.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for occupational history", "valueSets": "SNOMED CT : - ^ \u003Ca href=\"https://termbrowser.nhs.uk/?perspective=full&conceptId1=999001571000000109&edition=uk-edition&release=&server=https://termbrowser.nhs.uk/sct-browser-api/snomed&langRefset=999001261000000100,999000691000001104\" target=\"\" title=\"\"\u003E999001571000000109\u003C/a\u003E | Occupation 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": "Performing professional", "description": "The professional who took the occupational history.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the professional.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc", "valueSets": "FHIR value set :- \u003Ca class=\"\" href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobroletype\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the professional.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Speciality", "description": "The specialty of the professional e.g. physiotherapy, oncology, mental health etc", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The name of the organisation the professional works for." }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the professional", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK phone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person completing record", "description": "Details of the person completing the record.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The organisational role of the person completing record.", "valueSets": "FHIR value set :- \u003Ca href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobrole\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Specialty", "description": "The main specialty of the person completing the record.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The organisation the person completing the record works for.", "valueSets": "\n \u003Cspan style=\"color: rgb(51, 51, 51); font-family: Arial, Helvetica, Geneva, sans-serif; font-size: 12px;\"\u003ENHS data dictionary : - \u003C/span\u003E \n \u003Ca href=\"https://www.datadictionary.nhs.uk/supporting_information/organisation_data_service.html\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date completed", "description": "The date and time the record was completed.", "valueSets": "Date and time.", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the person completing the record. \u003Cbr clear=\"none\"/\u003E \n ", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK telephone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Educational history", "description": "Details of the person's educational history.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date", "description": "The date when the educational history was taken.", "valueSets": "Date and time.", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Location", "description": "The location where the education history was taken.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for location.", "valueSets": "NHS Data dictionary : - \u003Ca class=\"\" href=\"https://www.datadictionary.nhs.uk/data_dictionary/nhs_business_definitions/o/organisation_data_service_de.asp?shownav=1\" target=\"\" title=\"\"\u003EOrganisation data service code\u003C/a\u003E \n ", "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": "Educational history", "description": "The current and/or previous relevant educational history of the person.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Performing professional", "description": "The professional who took the educational history.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the professional.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc", "valueSets": "FHIR value set :- \u003Ca class=\"\" href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobroletype\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the professional.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Speciality", "description": "The specialty of the professional e.g. physiotherapy, oncology, mental health etc", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The name of the organisation the professional works for." }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the professional", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK phone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person completing record", "description": "Details of the person completing the record.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The organisational role of the person completing record.", "valueSets": "FHIR value set :- \u003Ca href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobrole\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Specialty", "description": "The main specialty of the person completing the record.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The organisation the person completing the record works for.", "valueSets": "\n \u003Cspan style=\"color: rgb(51, 51, 51); font-family: Arial, Helvetica, Geneva, sans-serif; font-size: 12px;\"\u003ENHS data dictionary : - \u003C/span\u003E \n \u003Ca href=\"https://www.datadictionary.nhs.uk/supporting_information/organisation_data_service.html\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date completed", "description": "The date and time the record was completed.", "valueSets": "Date and time.", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the person completing the record. \u003Cbr clear=\"none\"/\u003E \n ", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK telephone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Lifestyle choices", "description": "The lifestyle choices made by the person which are pertinent to his or her health and well-being, e.g. physical activity level, pets, hobbies and sexual habits", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date", "description": "The date when the lifestyle choices were taken.", "valueSets": "Date and time.", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Location", "description": "The location where the lifestyle choices were taken.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for location.", "valueSets": "NHS Data dictionary : - \u003Ca class=\"\" href=\"https://www.datadictionary.nhs.uk/data_dictionary/nhs_business_definitions/o/organisation_data_service_de.asp?shownav=1\" target=\"\" title=\"\"\u003EOrganisation data service code\u003C/a\u003E \n ", "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": "Lifestyle choices", "description": "The lifestyle choices made by the person which are pertinent to his or her health and well-being, e.g. physical activity level, pets, hobbies and sexual preferences.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Performing professional", "description": "The professional who took the lifestyle choices.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the professional.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc", "valueSets": "FHIR value set :- \u003Ca class=\"\" href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobroletype\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the professional.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Speciality", "description": "The specialty of the professional e.g. physiotherapy, oncology, mental health etc", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The name of the organisation the professional works for." }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the professional", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK phone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person completing record", "description": "Details of the person completing the record.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The organisational role of the person completing record.", "valueSets": "FHIR value set :- \u003Ca href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobrole\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Specialty", "description": "The main specialty of the person completing the record.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The organisation the person completing the record works for.", "valueSets": "\n \u003Cspan style=\"color: rgb(51, 51, 51); font-family: Arial, Helvetica, Geneva, sans-serif; font-size: 12px;\"\u003ENHS data dictionary : - \u003C/span\u003E \n \u003Ca href=\"https://www.datadictionary.nhs.uk/supporting_information/organisation_data_service.html\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date completed", "description": "The date and time the record was completed.", "valueSets": "Date and time.", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the person completing the record. \u003Cbr clear=\"none\"/\u003E \n ", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK telephone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Smoking status", "description": "Details of the person's smoking status.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date", "description": "The date when the smoking status was taken.", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Location", "description": "The location where the smoking status was taken.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for location", "valueSets": "NHS data dictionary : - \u003Ca class=\"\" href=\"https://www.datadictionary.nhs.uk/data_dictionary/nhs_business_definitions/o/organisation_data_service_de.asp?shownav=1\" target=\"\" title=\"\"\u003EOrganisation data service code\u003C/a\u003E \n ", "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": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Smoking status", "description": "\n \u003Cdiv\u003ERecord of any smoking use by the person.\u003C/div\u003E \n ", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The smoking status of the person.", "valueSets": "SNOMED CT:- \u003Ca href=\"https://termbrowser.nhs.uk/?perspective=full&conceptId1=999000891000000102&edition=uk-edition&release=&server=https://termbrowser.nhs.uk/sct-browser-api/snomed&langRefset=999001261000000100,999000691000001104\" target=\"\" title=\"\"\u003E^999000891000000102 |Smoking simple reference set (foundation metadata concept)|\u003C/a\u003E \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": "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": "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": "SNOMED CT:- \u003Ca href=\"https://termbrowser.nhs.uk/?perspective=full&conceptId1=999000891000000102&edition=uk-edition&release=&server=https://termbrowser.nhs.uk/sct-browser-api/snomed&langRefset=999001261000000100,999000691000001104\" target=\"\" title=\"\"\u003E160625004\u003C/a\u003E |Date ceased smoking (observable entity)|" }, { "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": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Performing professional", "description": "The professional who took the smoking status.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the professional.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc", "valueSets": "FHIR value set :- \u003Ca class=\"\" href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobroletype\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the professional.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Speciality", "description": "The specialty of the professional e.g. physiotherapy, oncology, mental health etc", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The name of the organisation the professional works for." }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the professional", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK phone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person completing record", "description": "Details of the person completing the record.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The organisational role of the person completing record.", "valueSets": "FHIR value set :- \u003Ca href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobrole\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Specialty", "description": "The main specialty of the person completing the record.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The organisation the person completing the record works for.", "valueSets": "\n \u003Cspan style=\"color: rgb(51, 51, 51); font-family: Arial, Helvetica, Geneva, sans-serif; font-size: 12px;\"\u003ENHS data dictionary : - \u003C/span\u003E \n \u003Ca href=\"https://www.datadictionary.nhs.uk/supporting_information/organisation_data_service.html\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date completed", "description": "The date and time the record was completed.", "valueSets": "Date and time.", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the person completing the record. \u003Cbr clear=\"none\"/\u003E \n ", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK telephone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Alcohol intake", "description": "Details of the person's alcohol intake", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date", "description": "The date when the alcohol intake was noted.", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Location", "description": "The location where the alcohol intake was noted.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for location.", "valueSets": "NHS Data dictionary : - \u003Ca class=\"\" href=\"https://www.datadictionary.nhs.uk/data_dictionary/nhs_business_definitions/o/organisation_data_service_de.asp?shownav=1\" target=\"\" title=\"\"\u003EOrganisation data service code\u003C/a\u003E \n ", "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": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Alcohol intake", "description": "Latest or current alcohol consumption.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value of the person alcohol intake", "valueSets": "SNOMED CT :- 219006 |Current drinker of alcohol (finding)| OR 105542008 |Current non-drinker of alcohol (finding)| OR 228274009 |Lifetime non-drinker (finding)| OR 1104551000000109 |Declined to provide information about alcohol use (situation)| OR 371434005 |History of alcohol abuse (situation)|" }, { "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": "Performing professional", "description": "The professional who noted the alcohol intake.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the professional.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc", "valueSets": "FHIR value set :- \u003Ca class=\"\" href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobroletype\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the professional.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Speciality", "description": "The specialty of the professional e.g. physiotherapy, oncology, mental health etc", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The name of the organisation the professional works for." }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the professional", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK phone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person completing record", "description": "Details of the person completing the record.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The organisational role of the person completing record.", "valueSets": "FHIR value set :- \u003Ca href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobrole\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Specialty", "description": "The main specialty of the person completing the record.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The organisation the person completing the record works for.", "valueSets": "\n \u003Cspan style=\"color: rgb(51, 51, 51); font-family: Arial, Helvetica, Geneva, sans-serif; font-size: 12px;\"\u003ENHS data dictionary : - \u003C/span\u003E \n \u003Ca href=\"https://www.datadictionary.nhs.uk/supporting_information/organisation_data_service.html\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date completed", "description": "The date and time the record was completed.", "valueSets": "Date and time.", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the person completing the record. \u003Cbr clear=\"none\"/\u003E \n ", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK telephone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Drug/substance use", "description": "Details of the person's drug and substance use.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date", "description": "The date when the drug/substance use was noted.", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Location", "description": "The location where the drug/substance use was noted.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for location.", "valueSets": "NHS Data dictionary : - \u003Ca class=\"\" href=\"https://www.datadictionary.nhs.uk/data_dictionary/nhs_business_definitions/o/organisation_data_service_de.asp?shownav=1\" target=\"\" title=\"\" style=\"outline: 0px;\"\u003EOrganisation data service code\u003C/a\u003E \n ", "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": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Drug/substance use", "description": "Latest or current drug/substance use.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for drug and substance misuse.", "valueSets": "SNOMED CT:- 361055000 |Misuses drugs (finding)| OR 371422002 |History of substance abuse (situation)| OR 228368007 |Has never misused drugs (situation)| OR 783241000000102 |Declined to give substance misuse history (finding)|" }, { "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": "Performing professional", "description": "The professional who noted the drug/substance use.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the professional.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc", "valueSets": "FHIR value set :- \u003Ca class=\"\" href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobroletype\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the professional.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Speciality", "description": "The specialty of the professional e.g. physiotherapy, oncology, mental health etc", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The name of the organisation the professional works for." }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the professional", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK phone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person completing record", "description": "Details of the person completing the record.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The organisational role of the person completing record.", "valueSets": "FHIR value set :- \u003Ca href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobrole\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Specialty", "description": "The main specialty of the person completing the record.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The organisation the person completing the record works for.", "valueSets": "\n \u003Cspan style=\"color: rgb(51, 51, 51); font-family: Arial, Helvetica, Geneva, sans-serif; font-size: 12px;\"\u003ENHS data dictionary : - \u003C/span\u003E \n \u003Ca href=\"https://www.datadictionary.nhs.uk/supporting_information/organisation_data_service.html\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date completed", "description": "The date and time the record was completed.", "valueSets": "Date and time.", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the person completing the record. \u003Cbr clear=\"none\"/\u003E \n ", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK telephone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Social circumstances", "description": "Details of the persons social circumstances", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date", "description": "The date when the social circumstances were taken.", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Location", "description": "The location where the social circumstances were taken.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for the location", "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": "Social circumstances", "description": "A person’s social background, network and personal circumstances, e.g. housing. This should include whether the person is a \u003Ca href=\"https://datadictionary.nhs.uk/nhs_business_definitions/carer.html\" target=\"\" title=\"\"\u003Ecarer\u003C/a\u003E .", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Performing professional", "description": "The professional who took the social circumstances.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the professional.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc", "valueSets": "FHIR value set :- \u003Ca class=\"\" href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobroletype\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the professional.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Speciality", "description": "The specialty of the professional e.g. physiotherapy, oncology, mental health etc", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The name of the organisation the professional works for." }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the professional", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK phone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person completing record", "description": "Details of the person completing the record.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The organisational role of the person completing record.", "valueSets": "FHIR value set :- \u003Ca href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobrole\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Specialty", "description": "The main specialty of the person completing the record.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The organisation the person completing the record works for.", "valueSets": "\n \u003Cspan style=\"color: rgb(51, 51, 51); font-family: Arial, Helvetica, Geneva, sans-serif; font-size: 12px;\"\u003ENHS data dictionary : - \u003C/span\u003E \n \u003Ca href=\"https://www.datadictionary.nhs.uk/supporting_information/organisation_data_service.html\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date completed", "description": "The date and time the record was completed.", "valueSets": "Date and time.", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the person completing the record. \u003Cbr clear=\"none\"/\u003E \n ", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK telephone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Access", "description": "Details of access for the person.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date", "description": "The date when the special access requirements were taken.", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Location", "description": "The location where the special access requirements were taken.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for location", "valueSets": "NHS Data dictionary : - \u003Ca class=\"\" href=\"https://www.datadictionary.nhs.uk/data_dictionary/nhs_business_definitions/o/organisation_data_service_de.asp?shownav=1\" target=\"\" title=\"\" style=\"outline: 0px;\"\u003EOrganisation data service code\u003C/a\u003E \n ", "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 coded text available", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Access", "description": "Special access requirements e.g. key safe, coded lock, which door to use, stretcher access, etc.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Performing professional", "description": "The professional who took the special access requirements.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the professional.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc", "valueSets": "FHIR value set :- \u003Ca class=\"\" href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobroletype\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the professional.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Speciality", "description": "The specialty of the professional e.g. physiotherapy, oncology, mental health etc", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The name of the organisation the professional works for." }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the professional", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK phone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person completing record", "description": "Details of the person completing the record.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The organisational role of the person completing record.", "valueSets": "FHIR value set :- \u003Ca href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobrole\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Specialty", "description": "The main specialty of the person completing the record.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The organisation the person completing the record works for.", "valueSets": "\n \u003Cspan style=\"color: rgb(51, 51, 51); font-family: Arial, Helvetica, Geneva, sans-serif; font-size: 12px;\"\u003ENHS data dictionary : - \u003C/span\u003E \n \u003Ca href=\"https://www.datadictionary.nhs.uk/supporting_information/organisation_data_service.html\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date completed", "description": "The date and time the record was completed.", "valueSets": "Date and time.", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the person completing the record. \u003Cbr clear=\"none\"/\u003E \n ", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK telephone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Dependants", "description": "Details of any responsibility the person has for dependants.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date", "description": "The date when the dependents details were taken.", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Location", "description": "The location where the dependents details were taken.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for location", "valueSets": "NHS Data dictionary : - \u003Ca class=\"\" href=\"https://www.datadictionary.nhs.uk/data_dictionary/nhs_business_definitions/o/organisation_data_service_de.asp?shownav=1\" target=\"\" title=\"\" style=\"outline: 0px;\"\u003EOrganisation data service code\u003C/a\u003E \n ", "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": "Dependants", "description": "Provide details of any responsibility the person has for dependants. In the case of children provide date of birth of the child.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Performing professional", "description": "The professional who took the dependents details.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the professional.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc", "valueSets": "FHIR value set :- \u003Ca class=\"\" href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobroletype\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the professional.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Speciality", "description": "The specialty of the professional e.g. physiotherapy, oncology, mental health etc", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The name of the organisation the professional works for." }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the professional", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK phone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person completing record", "description": "Details of the person completing the record.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The organisational role of the person completing record.", "valueSets": "FHIR value set :- \u003Ca href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobrole\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Specialty", "description": "The main specialty of the person completing the record.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The organisation the person completing the record works for.", "valueSets": "\n \u003Cspan style=\"color: rgb(51, 51, 51); font-family: Arial, Helvetica, Geneva, sans-serif; font-size: 12px;\"\u003ENHS data dictionary : - \u003C/span\u003E \n \u003Ca href=\"https://www.datadictionary.nhs.uk/supporting_information/organisation_data_service.html\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date completed", "description": "The date and time the record was completed.", "valueSets": "Date and time.", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the person completing the record. \u003Cbr clear=\"none\"/\u003E \n ", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK telephone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Accommodation status", "description": "Details of the type of accommodation where the person lives.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date", "description": "The date when the accommodation status was taken.", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Location", "description": "The location where the accommodation was taken.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value of location", "valueSets": "NHS Data dictionary : - \u003Ca class=\"\" href=\"https://www.datadictionary.nhs.uk/data_dictionary/nhs_business_definitions/o/organisation_data_service_de.asp?shownav=1\" target=\"\" title=\"\"\u003EOrganisation data service code\u003C/a\u003E \n ", "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": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Accommodation status", "description": "An indication of the type of accommodation where the person lives. \u003Cbr clear=\"none\"/\u003E \n \u003Cbr clear=\"none\"/\u003E This should be based on the main or permanent residence.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for accommodation status", "valueSets": "NHS data dictionary :- \u003Ca href=\"http://www.datadictionary.nhs.uk/data_dictionary/attributes/a/acc/accommodation_status_code_de.asp?shownav=1?query=%22accommodation%22&rank=66.66667&shownav=1\" target=\"\" title=\"\"\u003EAccommodation status\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "4" } ] } ] }, { "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": "Performing professional", "description": "The professional who took the accommodation status.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the professional.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc", "valueSets": "FHIR value set :- \u003Ca class=\"\" href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobroletype\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the professional.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Speciality", "description": "The specialty of the professional e.g. physiotherapy, oncology, mental health etc", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The name of the organisation the professional works for." }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the professional", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK phone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person completing record", "description": "Details of the person completing the record.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The organisational role of the person completing record.", "valueSets": "FHIR value set :- \u003Ca href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobrole\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Specialty", "description": "The main specialty of the person completing the record.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The organisation the person completing the record works for.", "valueSets": "\n \u003Cspan style=\"color: rgb(51, 51, 51); font-family: Arial, Helvetica, Geneva, sans-serif; font-size: 12px;\"\u003ENHS data dictionary : - \u003C/span\u003E \n \u003Ca href=\"https://www.datadictionary.nhs.uk/supporting_information/organisation_data_service.html\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date completed", "description": "The date and time the record was completed.", "valueSets": "Date and time.", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the person completing the record. \u003Cbr clear=\"none\"/\u003E \n ", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK telephone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Household environment", "description": "Details of the person's household environment.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date", "description": "The date when the household environment details were taken.", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Location", "description": "The location where the household environment details were taken.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for location", "valueSets": "NHS Data dictionary : - \u003Ca class=\"\" href=\"https://www.datadictionary.nhs.uk/data_dictionary/nhs_business_definitions/o/organisation_data_service_de.asp?shownav=1\" target=\"\" title=\"\"\u003EOrganisation data service code\u003C/a\u003E \n ", "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": "Household environment", "description": "Factors in the household which impact the person's health and wellbeing, to include smoking in the home, alcohol/substance use etc.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "minLength": "3", "maxLength": "5" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Performing professional", "description": "The professional who took the household environment details.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the professional.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc", "valueSets": "FHIR value set :- \u003Ca class=\"\" href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobroletype\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the professional.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Speciality", "description": "The specialty of the professional e.g. physiotherapy, oncology, mental health etc", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The name of the organisation the professional works for." }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the professional", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK phone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person completing record", "description": "Details of the person completing the record.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The organisational role of the person completing record.", "valueSets": "FHIR value set :- \u003Ca href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobrole\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Specialty", "description": "The main specialty of the person completing the record.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The organisation the person completing the record works for.", "valueSets": "\n \u003Cspan style=\"color: rgb(51, 51, 51); font-family: Arial, Helvetica, Geneva, sans-serif; font-size: 12px;\"\u003ENHS data dictionary : - \u003C/span\u003E \n \u003Ca href=\"https://www.datadictionary.nhs.uk/supporting_information/organisation_data_service.html\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date completed", "description": "The date and time the record was completed.", "valueSets": "Date and time.", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the person completing the record. \u003Cbr clear=\"none\"/\u003E \n ", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK telephone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Services and care", "implementationGuidance": "This section is a record of the services being provided (or that have previously been provided) to the person to support both health and social well-being. For example, it could include domiciliary care with help for washing and feeding. A start and end date for the services should also be provided where available so it is clear which services are currently being provided. The professional or organisation providing the service, along with contact details should be made available where possible (in the ‘Performing professional’ subsection). \u003Cbr clear=\"none\"/\u003E \n ", "description": "The services and care provided for the person.", "concept": [ { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Services and care record entry", "description": "This is a services and care 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.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Social care package name", "description": "Name of specific type of package being provided (e.g. Reablement, Home Based Care XYZ, etc)", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Social care package type", "description": "Higher level categorisation of package type, e.g. Adults Home Support", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Service start date", "description": "The date service started to be provided.", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Service end date", "description": "The date the service is planned to be ended or the actual end date.", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Local authority", "description": "The name of the local authority providing the care package.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for local authority", "valueSets": "NHS data dictionary: - \u003Ca href=\"https://www.datadictionary.nhs.uk/data_dictionary/attributes/o/org/organisation_code_de.asp?shownav=1\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n ", "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": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Care funding source", "implementationGuidance": "See CIS-Implementation-Guidance_v2.01", "description": "A reference to the funding source and any conditions or limitations associated." }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Performing professional", "description": "The professional providing the service.", "valueSets": "Free text", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the professional.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc", "valueSets": "FHIR value set :- \u003Ca class=\"\" href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobroletype\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the professional.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Speciality", "description": "The specialty of the professional e.g. physiotherapy, oncology, mental health etc", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The name of the organisation the professional works for." }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the professional", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK phone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person completing record", "description": "Details of the person completing the record.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The organisational role of the person completing record.", "valueSets": "FHIR value set :- \u003Ca href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobrole\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Specialty", "description": "The main specialty of the person completing the record.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The organisation the person completing the record works for.", "valueSets": "\n \u003Cspan style=\"color: rgb(51, 51, 51); font-family: Arial, Helvetica, Geneva, sans-serif; font-size: 12px;\"\u003ENHS data dictionary : - \u003C/span\u003E \n \u003Ca href=\"https://www.datadictionary.nhs.uk/supporting_information/organisation_data_service.html\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date completed", "description": "The date and time the record was completed.", "valueSets": "Date and time.", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the person completing the record. \u003Cbr clear=\"none\"/\u003E \n ", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK telephone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Primary support reason", "description": "The primary support reason for social care.", "concept": [ { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Primary support reason record entry", "description": "This is a primary support reason 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.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Primary support reason", "description": "The Primary Support Reason used to classify a person for National Reporting on Short and Long Term Services (SALT) e.g. Learning disability support, mental health support, physical support", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Active", "description": "Flag to indicate whether the primary support reason is currently active", "valueSets": "Flag: - Yes or No", "valueDomain": [ { "type": "boolean" } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Start date", "description": "The date a primary support reason was authorised as active.", "valueSets": "Date and time", "valueDomain": [ { "type": "date", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "End date", "description": "The end date of authorisation.", "valueSets": "Date and time", "valueDomain": [ { "type": "date", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Family history", "implementationGuidance": "This section includes information on conditions or illness in family relations relevant to the health or care of the person. \u003Cbr clear=\"none\"/\u003E \n ", "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.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date", "description": "The date the family history was taken.", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Location", "description": "The location where the family history was taken.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for location", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://www.datadictionary.nhs.uk/data_dictionary/attributes/o/org/organisation_code_de.asp?shownav=1\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n ", "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": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Performing professional", "description": "The professional who took the family history.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the professional.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc", "valueSets": "FHIR value set :- \u003Ca class=\"\" href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobroletype\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the professional.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Speciality", "description": "The specialty of the professional e.g. physiotherapy, oncology, mental health etc", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The name of the organisation the professional works for." }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the professional", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK phone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Relationship to person", "description": "The relationship of the family member with the condition to the person.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for relationship to person", "valueSets": "SNOMED CT: - <303071001 |Person in the family (person)| \u003Cbr clear=\"none\"/\u003E \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": "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.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for family history", "valueSets": "SNOMED CT:- <404684003 |Clinical finding (finding)| OR <243796009 |Situation with explicit context (situation)| \u003Cbr clear=\"none\"/\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "description": "Free text field to be used if no coded text available", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person completing record", "description": "Details of the person completing the record.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The organisational role of the person completing record.", "valueSets": "FHIR value set :- \u003Ca href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobrole\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Specialty", "description": "The main specialty of the person completing the record.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The organisation the person completing the record works for.", "valueSets": "\n \u003Cspan style=\"color: rgb(51, 51, 51); font-family: Arial, Helvetica, Geneva, sans-serif; font-size: 12px;\"\u003ENHS data dictionary : - \u003C/span\u003E \n \u003Ca href=\"https://www.datadictionary.nhs.uk/supporting_information/organisation_data_service.html\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date completed", "description": "The date and time the record was completed.", "valueSets": "Date and time.", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the person completing the record. \u003Cbr clear=\"none\"/\u003E \n ", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK telephone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Comment", "description": "Any further textual comment.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Investigation results", "implementationGuidance": "This section includes details of the investigation results. Systems should allow copies of reports, scans, images related to the investigation results to be shared with the record. It allows for results in either structured format (e.g. blood tests) or unstructured format (e.g. genetic test with the result as a report). One or other of these should be used for the result. Investigation results received from laboratories may be imported into this section. \u003Cbr clear=\"none\"/\u003E \n ", "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.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date", "description": "The date and time when the investigation was performed", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Performing professional", "description": "The professional who performed the investigation.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the professional.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc", "valueSets": "FHIR value set :- \u003Ca class=\"\" href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobroletype\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the professional.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Speciality", "description": "The specialty of the professional e.g. physiotherapy, oncology, mental health etc", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The name of the organisation the professional works for." }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the professional", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK phone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Location", "description": "The location where the investigation took place.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded location", "description": "The coded value for location", "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": "group", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "M", "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": "SNOMED CT: - <71388002 |Procedure (procedure)| \u003Cbr clear=\"none\"/\u003E \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": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Investigation result", "description": "For each investigation, the result of the investigation. This can include a report which may have results for multiple tests.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Coded value", "description": "The coded value for investigation results", "valueSets": "SNOMED CT:- <404684003 |Clinical finding (finding)| OR <243796009 |Situation with explicit context (situation)| \u003Cbr clear=\"none\"/\u003E \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": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Structured investigation result", "description": "A structured set of information for each investigation result.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Value", "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": "Person completing record", "description": "Details of the person completing the record.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The organisational role of the person completing record.", "valueSets": "FHIR value set :- \u003Ca href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobrole\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Specialty", "description": "The main specialty of the person completing the record.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The organisation the person completing the record works for.", "valueSets": "\n \u003Cspan style=\"color: rgb(51, 51, 51); font-family: Arial, Helvetica, Geneva, sans-serif; font-size: 12px;\"\u003ENHS data dictionary : - \u003C/span\u003E \n \u003Ca href=\"https://www.datadictionary.nhs.uk/supporting_information/organisation_data_service.html\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date completed", "description": "The date and time the record was completed.", "valueSets": "Date and time.", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the person completing the record. \u003Cbr clear=\"none\"/\u003E \n ", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK telephone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Investigations requested", "implementationGuidance": "The section includes details of requested investigations as yet unfulfilled. This should include the reason and priority of the request. \u003Cbr clear=\"none\"/\u003E \n Investigations that have concluded, and for which results are available, should be included in the investigation results section. \u003Cbr clear=\"none\"/\u003E \n ", "description": "Details of any investigations requested", "concept": [ { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Investigations requested record entry", "description": "This is an investigation requested record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date", "description": "The date the investigation was requested.", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Location", "description": "The location where the investigation was requested.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for location", "valueSets": "NHS data dictionary: - \u003Ca href=\"https://www.datadictionary.nhs.uk/data_dictionary/attributes/o/org/organisation_code_de.asp?shownav=1\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n ", "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 coded text available", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Performing professional", "description": "The professional who requested the investigation.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the professional.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc", "valueSets": "FHIR value set :- \u003Ca class=\"\" href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobroletype\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the professional.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Speciality", "description": "The specialty of the professional e.g. physiotherapy, oncology, mental health etc", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The name of the organisation the professional works for." }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the professional", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK phone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "R", "name": "Investigation requested", "description": "The investigation that is requested. The investigation may refer to an individual test or a group of related tests or broader investigation required (so the investigator can determine the appropriate tests)", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for Investigation requested", "valueSets": "SNOMED CT: - \u003C71388002 |Procedure (procedure)|" }, { "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": "Status of request", "description": "The status of the investigation request.", "valueSets": "Code : - draft | active | suspended | completed | entered-in-error | cancelled", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "16" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Reason for request", "description": "An explanation or justification for why this investigation is being requested.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Request priority", "description": "The urgency of the investigation requested.", "valueSets": "Code : - routine | urgent | asap | stat", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "10" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person completing record", "description": "Details of the person completing the record.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The organisational role of the person completing record.", "valueSets": "FHIR value set :- \u003Ca href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobrole\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Specialty", "description": "The main specialty of the person completing the record.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The organisation the person completing the record works for.", "valueSets": "\n \u003Cspan style=\"color: rgb(51, 51, 51); font-family: Arial, Helvetica, Geneva, sans-serif; font-size: 12px;\"\u003ENHS data dictionary : - \u003C/span\u003E \n \u003Ca href=\"https://www.datadictionary.nhs.uk/supporting_information/organisation_data_service.html\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date completed", "description": "The date and time the record was completed.", "valueSets": "Date and time.", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the person completing the record. \u003Cbr clear=\"none\"/\u003E \n ", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK telephone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Examination findings", "implementationGuidance": "This section is a summary of key findings carried out as a result of an examination conducted by a healthcare professional. \u003Cbr clear=\"none\"/\u003E \n Each record of an ‘Examination finding’ should include a named examination and associated findings, which may include both coded and narrative elements. \u003Cbr clear=\"none\"/\u003E \n ‘Observations’ includes a record of essential physiological measurements, e.g., heart rate, blood pressure, weight, height, temperature, pulse, respiratory rate, oxygen saturation. \u003Cbr clear=\"none\"/\u003E \n For children, observations would also include weight, height/length and head circumference. \u003Cbr clear=\"none\"/\u003E \n ", "description": "Examination findings", "concept": [ { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Examination findings record entry", "description": "This is a examination findings record entry. There may be 0 to many record entry/entries under a section. Each record entry is made up of a number of elements or data items.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date", "description": "The date the examination was performed.", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Performing professional", "description": "The professional who performed the examiniation.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the professional.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc", "valueSets": "FHIR value set :- \u003Ca class=\"\" href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobroletype\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the professional.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Speciality", "description": "The specialty of the professional e.g. physiotherapy, oncology, mental health etc", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The name of the organisation the professional works for." }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the professional", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK phone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Location", "description": "The location where the examination was performed.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for location", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/attributes/organisation_code.html?hl=organisation%2Cdata%2Cservice\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n ", "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": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Examination findings", "description": "The record of findings from the examinations performed.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for examination findings", "valueSets": "SNOMED CT : - ^1127601000000107 |Healthcare matters simple reference set (foundation metadata concept)| \u003Cbr clear=\"none\"/\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "description": "Free text field to be used if no coded text available", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Observations", "description": "The record of essential physiological measurements, e.g., heart rate, blood pressure, temperature, pulse, height, weight, respiratory rate, oxygen saturation.", "concept": [ { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Observations record entry", "description": "This is an observations record entry. There may be 0 to many record entry/entries under a section. Each record entry is made up of a number of elements or data items.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for observations", "valueSets": "SNOMED CT: - <363787002 | Observable entity (observable entity) | \u003Cbr clear=\"none\"/\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Value", "description": "The measured value of the observations", "valueSets": "Enumerated value e.g. numeric, natural numbers, mild, moderate", "valueDomain": [ { "type": "quantity" } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Units of measure", "description": "The units of measure for the observation.", "valueSets": "UCUM code", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "10" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Site", "description": "The anatomical site at which the observation is taken", "valueSets": "SNOMED CT: - 442083009 | Anatomical or acquired body structure (body structure) |" }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Interpretation", "description": "The assessment made based on the result of the observation e.g high, low", "valueSets": "FHIR value set: - \u003Ca href=\"http://hl7.org/fhir/stu3/valueset-observation-interpretation.html\" target=\"\" title=\"\"\u003EInterpretation\u003C/a\u003E \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": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Pregnancy status", "implementationGuidance": "This is to share if someone is currently pregnant and the expected due date. This information should only be shared if someone is pregnant. \u003Cbr clear=\"none\"/\u003E \n It seems unlikely that this information can be reliably imported from a single system and so, is likely, to be a calculated field. This is unique in this model and may be defined as a medical device, for which separate safety assessment and registration will be required. System manufacturers will need to consider this. \u003Cbr clear=\"none\"/\u003E \n Any maternity management plans or birth plans related to the pregnancy would be shared in the section ‘Additional Supporting Plans’. \u003Cbr clear=\"none\"/\u003E \n Obstetric and gynaecological history, specifically any complications, would be shared in the problem list (history) for professionals that need and are authorised to access to the information. \u003Cbr clear=\"none\"/\u003E \n If a person is pregnant there should be an electronic shared maternity record and if professionals need, and are authorised to access it, they should be able to link to the more detailed record. This would be through the national record locator service. \u003Cbr clear=\"none\"/\u003E \n ", "description": "Pregnancy status of the person.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date", "description": "The date the observation was recorded", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Location", "description": "The location where the pregnancy state details were recorded.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for location.", "valueSets": "NHS data dictionary: - \u003Ca href=\"https://www.datadictionary.nhs.uk/data_dictionary/attributes/o/org/organisation_code_de.asp?shownav=1\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n ", "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": "Pregnancy state", "description": "A flag that indicates whether the person is pregnant.", "valueSets": "Flag : - Yes or No", "valueDomain": [ { "type": "boolean" } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Expected delivery date", "description": "The expected delivery date of the person.", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMD" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Performing professional", "description": "The professional who observed the pregnancy", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the professional.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc", "valueSets": "FHIR value set :- \u003Ca class=\"\" href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobroletype\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the professional.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Speciality", "description": "The specialty of the professional e.g. physiotherapy, oncology, mental health etc", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The name of the organisation the professional works for.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for location", "valueSets": "NHS data dictionary: - \u003Ca href=\"https://www.datadictionary.nhs.uk/data_dictionary/attributes/o/org/organisation_code_de.asp?shownav=1\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "minLength": "3", "maxLength": "7" } ] } ] }, { "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": "Contact details of the professional", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK phone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person completing record", "description": "Details of the person completing the record.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The organisational role of the person completing record.", "valueSets": "FHIR value set :- \u003Ca href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobrole\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Specialty", "description": "The main specialty of the person completing the record.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The organisation the person completing the record works for.", "valueSets": "\n \u003Cspan style=\"color: rgb(51, 51, 51); font-family: Arial, Helvetica, Geneva, sans-serif; font-size: 12px;\"\u003ENHS data dictionary : - \u003C/span\u003E \n \u003Ca href=\"https://www.datadictionary.nhs.uk/supporting_information/organisation_data_service.html\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n ", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for location", "valueSets": "NHS data dictionary : - \u003Ca class=\"\" href=\"https://www.datadictionary.nhs.uk/data_dictionary/attributes/o/org/organisation_code_de.asp?shownav=1\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "minLength": "3", "maxLength": "7" } ] } ] }, { "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": "Professional identifier", "description": "Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date completed", "description": "The date and time the record was completed.", "valueSets": "Date and time.", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the person completing the record. \u003Cbr clear=\"none\"/\u003E \n ", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK telephone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Assessments", "implementationGuidance": "This section includes details of a person’s assessments allowing for unstructured, semistructured and structured outputs from the assessment. Some assessment outputs will be narrative and may come with their own particular sub-headings e.g. psychiatry (Presenting Problem, Personal/Family History, Mental State Examination etc.) \u003Cbr clear=\"none\"/\u003E \n This section would also accommodate the results of any more structured assessment tools completed (e.g. screening tools/outcomes measures such as PHQ-9 or GAD-7). Numeric results of any assessments completed can also be included. \u003Cbr clear=\"none\"/\u003E \n ", "description": "Details of the person's assessments", "concept": [ { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "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.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date", "description": "The date the assessment was done.", "valueSets": "Date and time.", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Location", "description": "The location where the assessment was done.", "valueSets": "ODS code or free text.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for location", "valueSets": "NHS data dictionary: - \u003Ca href=\"https://www.datadictionary.nhs.uk/data_dictionary/attributes/o/org/organisation_code_de.asp?shownav=1\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n ", "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": "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": "item", "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.", "valueSets": "SNOMED CT" }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Assessment score", "description": "The structured assessment score.", "valueSets": "Free text." }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Assessment value", "description": "The structured assessment value.", "valueSets": "Numeric", "valueDomain": [ { "type": "quantity" } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Subscale score", "description": "The subscale score of the structured assessment.", "valueSets": "Free text." }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Subscale value", "description": "The subscale value of the structured assessment.", "valueSets": "Numeric", "valueDomain": [ { "type": "quantity" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Performing professional", "description": "The professional who did the assessment.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the professional.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc", "valueSets": "FHIR value set :- \u003Ca class=\"\" href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobroletype\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the professional.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Speciality", "description": "The specialty of the professional e.g. physiotherapy, oncology, mental health etc", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The name of the organisation the professional works for." }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the professional", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK phone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person completing record", "description": "Details of the person completing the record.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The organisational role of the person completing record.", "valueSets": "FHIR value set :- \u003Ca href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobrole\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Specialty", "description": "The main specialty of the person completing the record.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The organisation the person completing the record works for.", "valueSets": "\n \u003Cspan style=\"color: rgb(51, 51, 51); font-family: Arial, Helvetica, Geneva, sans-serif; font-size: 12px;\"\u003ENHS data dictionary : - \u003C/span\u003E \n \u003Ca href=\"https://www.datadictionary.nhs.uk/supporting_information/organisation_data_service.html\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date completed", "description": "The date and time the record was completed.", "valueSets": "Date and time.", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the person completing the record. \u003Cbr clear=\"none\"/\u003E \n ", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK telephone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Comment", "description": "Supporting text may be given regarding the assessment.", "valueSets": "Free text", "valueDomain": [ { "type": "string" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Formulation", "implementationGuidance": "This section includes the formulation. A formulation is an account, shared by a therapist and person, of the personal meaning and origins of a person’s difficulties. This is viewed in the context of multiple factors including relationships, social circumstances and life events and will indicate the most helpful way forward. \u003Cbr clear=\"none\"/\u003E \n ", "description": "Details of the person's formulation.", "concept": [ { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Formulation record entry", "description": "This is the formulation 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.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date", "description": "The date the formulation was made.", "valueSets": "Date and time.", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Location", "description": "The location where the formulation was made.", "valueSets": "NHS data dictionary: - \u003Ca class=\"\" href=\"https://www.datadictionary.nhs.uk/data_dictionary/attributes/o/org/organisation_code_de.asp?shownav=1\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n ", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for location", "valueSets": "NHS data dictionary: - \u003Ca class=\"\" href=\"https://www.datadictionary.nhs.uk/data_dictionary/attributes/o/org/organisation_code_de.asp?shownav=1\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n ", "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": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Performing professional", "description": "The professional who made the formulation.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the professional.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc", "valueSets": "FHIR value set :- \u003Ca class=\"\" href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobroletype\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the professional.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Speciality", "description": "The specialty of the professional e.g. physiotherapy, oncology, mental health etc", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The name of the organisation the professional works for." }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the professional", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK phone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] }, { "type": "item", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "M", "name": "Formulation", "description": "An account, shared by a therapist and person, of the personal meaning and origins of a person’s difficulties. This is viewed in the context of multiple factors including relationships, social circumstances and life events and will indicate the most helpful way forward.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person completing record", "description": "Details of the person completing the record.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The organisational role of the person completing record.", "valueSets": "FHIR value set :- \u003Ca href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobrole\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Specialty", "description": "The main specialty of the person completing the record.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The organisation the person completing the record works for.", "valueSets": "\n \u003Cspan style=\"color: rgb(51, 51, 51); font-family: Arial, Helvetica, Geneva, sans-serif; font-size: 12px;\"\u003ENHS data dictionary : - \u003C/span\u003E \n \u003Ca href=\"https://www.datadictionary.nhs.uk/supporting_information/organisation_data_service.html\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n ", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for location", "valueSets": "NHS data dictionary : - \u003Ca class=\"\" href=\"https://www.datadictionary.nhs.uk/data_dictionary/attributes/o/org/organisation_code_de.asp?shownav=1\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "minLength": "3", "maxLength": "7" } ] } ] }, { "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": "Professional identifier", "description": "Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date completed", "description": "The date and time the record was completed.", "valueSets": "Date and time.", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the person completing the record. \u003Cbr clear=\"none\"/\u003E \n ", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK telephone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Risks", "implementationGuidance": "Risks are likely to fall into the categories set out in the core information standard – Risk to self, risk to others, etc. However, there is also a category for other risks. \u003Cbr clear=\"none\"/\u003E \n There should be mechanisms in place to validate the information in this section and for it to be reviewed regularly and if applicable ended, however the peculiarity of risk factors in mental health needs to be taken into consideration i.e. the most important factor in risk is history so information here should not be archived or filtered without careful consideration. \u003Cbr clear=\"none\"/\u003E \n ", "description": "Details of any risks related to the person.", "concept": [ { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Risks", "description": "Details of the persons risks", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Start date of risk", "description": "The start date of the risk.", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "End date of risk", "description": "The date the risk ended.", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Risk", "description": "The risk to the person or others, this include's any risk the person might cause to them self or to others. e.g. suicide, self harm", "valueSets": "SNOMED CT: - <281694009 |Finding of at risk (finding)| \u003Cbr clear=\"none\"/\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Risk type", "description": "The type of risk being recorded e.g. self, to others, from others, risk of accidents, risk of infection and other risks", "valueSets": "Free text", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "30" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Location", "description": "The location where the risk was identified.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for location", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://www.datadictionary.nhs.uk/data_dictionary/attributes/o/org/organisation_code_de.asp?shownav=1\" target=\"\" title=\"\"\u003EOrganisation service code\u003C/a\u003E \n ", "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": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Performing professional", "description": "The professional who identified the risk.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the professional.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc", "valueSets": "FHIR value set :- \u003Ca class=\"\" href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobroletype\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the professional.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Speciality", "description": "The specialty of the professional e.g. physiotherapy, oncology, mental health etc", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The name of the organisation the professional works for." }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the professional", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK phone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person completing record", "description": "Details of the person completing the record.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The organisational role of the person completing record.", "valueSets": "FHIR value set :- \u003Ca href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobrole\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Specialty", "description": "The main specialty of the person completing the record.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The organisation the person completing the record works for.", "valueSets": "\n \u003Cspan style=\"color: rgb(51, 51, 51); font-family: Arial, Helvetica, Geneva, sans-serif; font-size: 12px;\"\u003ENHS data dictionary : - \u003C/span\u003E \n \u003Ca href=\"https://www.datadictionary.nhs.uk/supporting_information/organisation_data_service.html\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date completed", "description": "The date and time the record was completed.", "valueSets": "Date and time.", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the person completing the record. \u003Cbr clear=\"none\"/\u003E \n ", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK telephone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Allergies and adverse reactions", "implementationGuidance": "Guidance on good practice recording of allergies and adverse reactions is provided by NICE (https://www.nice.org.uk/guidance/CG183/chapter/1-Recommendations). \u003Cbr clear=\"none\"/\u003E \n A record should be provided of all allergic and adverse reactions relevant to the person. Coded information on causative agents is important to healthcare professionals to enable safe prescribing of medications. \u003Cbr clear=\"none\"/\u003E \n When an individual is diagnosed with an allergy related condition (e.g. anaphylactic shock or urticarial skin rash) this will be entered in addition into the diagnosis field in the healthcare system and will need to be cross referenced into the problem list and prominently displayed there. \u003Cbr clear=\"none\"/\u003E \n Where there is a diagnostic code for an allergy recorded in the system, the system should trigger an allergy entry. There is a significant risk to patient safety if allergies are not explicitly and prominently displayed. \u003Cbr clear=\"none\"/\u003E \n Adverse reactions need to be treated in a similar manner. \u003Cbr clear=\"none\"/\u003E \n Information about probability of recurrence may be included in the allergy comments element if this has been identified. \u003Cbr clear=\"none\"/\u003E \n ", "description": "Allergies and adverse reactions", "concept": [ { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Allergies and adverse reactions record entry", "description": "This is a allergies and adverse reactions record entry. There may be 1 to many record entries under a section. \u003Cbr clear=\"none\"/\u003E \n \u003Cbr clear=\"none\"/\u003E Each record entry is made up of a number of elements or data items.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Type of reaction", "description": "The type of reaction experienced by the person (allergic, adverse, intolerance)", "valueSets": "FHIR value set :- \u003Ca class=\"\" href=\"https://www.hl7.org/fhir/STU3/valueset-allergy-intolerance-type.html\" target=\"\" title=\"\"\u003EAllergy, Intolerance\u003C/a\u003E \n " }, { "type": "group", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "M", "name": "Causative agent", "description": "The agent such as food, drug or substances that has caused or may cause an allergy, intolerance or adverse reaction in this person Or “No known drug allergies or adverse reactions” Or “Information not available”", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for causative agent", "valueSets": "\n \u003Ctable class=\"detail spaced\" width=\"100%\" style=\"font-family: Arial, Helvetica, Geneva, sans-serif; font-size: 12px; max-width: 100%; background-image: initial; background-position: initial; background-size: initial; background-repeat: initial; background-attachment: initial; background-origin: initial; background-clip: initial; color: rgb(51, 51, 51);\"\u003E\n \u003Ctbody\u003E\n \u003Ctr\u003E\n \u003Ctd colspan=\"3\" rowspan=\"1\" style=\"vertical-align: top;\"\u003E\n \u003Cdiv class=\"xforms-control xforms-output xforms-mediatype-text-html xforms-mediatype-text\" id=\"xf-895≡xf-1239\" style=\"display: inline; zoom: 1;\"\u003E\n \u003Cdiv class=\"xforms-output-output\" id=\"xf-895≡xf-1239≡≡c\" style=\"zoom: 1;\"\u003Edm+d:- any code from the VTM, VMP, AMP, VMPP, AMPP and ingredient concept classes\u003C/div\u003E\n \u003C/div\u003E\n \u003C/td\u003E\n \u003C/tr\u003E\n \u003C/tbody\u003E\n \u003C/table\u003E \n \u003Cdiv\u003ESNOMED CT : - <105590001 |Substance OR <373873005 |Pharmaceutical / biologic product| OR <<716186003 |No known allergy| OR 196461000000101 |Transfer-degraded drug allergy| OR 196471000000108 |Transfer-degraded non-drug allergy)\u003Cbr clear=\"none\"/\u003E\n \u003C/div\u003E \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": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Reaction details cluster", "description": "Details of the reaction.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date", "description": "The date that the reaction was identified.", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Location", "description": "Details of where the allergy was identified. Linked to the date of the diagnosis by the professional.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for location.", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://www.datadictionary.nhs.uk/data_dictionary/attributes/o/org/organisation_code_de.asp?shownav=1\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n ", "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": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Substance", "description": "The substance, or a class of substances, that is considered to be responsible for the adverse reaction.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for substance", "valueSets": "SNOMED CT : - <105590001 | Substance (substance) | or <373873005 | Pharmaceutical / biologic product (product) | \u003Cbr clear=\"none\"/\u003E \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": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Description of reaction", "description": "A description of the manifestation of the allergic or adverse reaction experienced by the person. For example, skin rash.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for description of reaction.", "valueSets": "SNOMED CT: - ^1127581000000103 |Health issues simple reference set|" }, { "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": "Onset date", "description": "Date and time when manifestations showed e.g could be at home a few days earlier than the contact", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "Y" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Severity", "description": "A description of the severity of the reaction.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for severity", "valueSets": "FHIR value set : - \u003Ca href=\"https://simplifier.net/packages/hl7.fhir.r4.core/4.0.1/files/80724\" target=\"\" title=\"\"\u003ESeverity\u003C/a\u003E \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": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Certainty", "description": "A description of the certainty that the stated causative agent caused the allergic or adverse reaction.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for certainty.", "valueSets": "FHIR value set : - \u003Ca href=\"https://simplifier.net/packages/hl7.fhir.r4.core/4.0.1/files/80047\" target=\"\" title=\"\"\u003ECertainty\u003C/a\u003E \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": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Route of exposure", "description": "The route the person was exposed to the substance", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for route of exposure", "valueSets": "SNOMED CT: - ^999000051000001100 |ePrescribing route of administration simple reference set|" }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "description": "Free text field to be used if no coded text available", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Comment", "description": "Any additional comment or clarification about the adverse reaction.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Evidence", "description": "Results of investigations that confirmed the certainty of the diagnosis. Examples might include results of skin prick allergy tests", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date first experienced", "description": "When the reaction was first experienced i.e this may not be the first this has happened. May be a date or partial date (e.g. year) or text ( \u003Cb\u003Ee.g. during childhood\u003C/b\u003E )", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "Y" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Allergy end date", "description": "The date the allergy was diagnosed as ended", "valueSets": "Date and time ", "valueDomain": [ { "type": "date", "property": [ { "timeStampPrecision": "Y" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Comment", "description": "Any further comments on the person's allergies or adverse reactions.", "valueSets": "Free text", "valueDomain": [ { "type": "text" } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Performing professional", "description": "The professional who identified the reaction.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the professional.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc", "valueSets": "FHIR value set :- \u003Ca class=\"\" href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobroletype\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the professional.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Speciality", "description": "The specialty of the professional e.g. physiotherapy, oncology, mental health etc", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The name of the organisation the professional works for." }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the professional", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK phone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person completing record", "description": "Details of the person completing the record.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The organisational role of the person completing record.", "valueSets": "FHIR value set :- \u003Ca href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobrole\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Specialty", "description": "The main specialty of the person completing the record.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The organisation the person completing the record works for.", "valueSets": "\n \u003Cspan style=\"color: rgb(51, 51, 51); font-family: Arial, Helvetica, Geneva, sans-serif; font-size: 12px;\"\u003ENHS data dictionary : - \u003C/span\u003E \n \u003Ca href=\"https://www.datadictionary.nhs.uk/supporting_information/organisation_data_service.html\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date completed", "description": "The date and time the record was completed.", "valueSets": "Date and time.", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the person completing the record. \u003Cbr clear=\"none\"/\u003E \n ", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK telephone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Medications and medical devices", "implementationGuidance": "The medications section allows for using structured dose and timing information that is machine readable to facilitate the reading and transfer of medications information between systems and providers of care, through the structured dose direction cluster. Technical guidance for implementing the structured dose and timing in Fast Healthcare Interoperable Resource (FHIR) messaging is available from NHS Digital https://developer.nhs.uk/apis/dose-syntax-implementation/. \u003Cbr clear=\"none\"/\u003E \n The free text Dose directions description is the form of dosage direction typically used in UK GP Systems. \u003Cbr clear=\"none\"/\u003E \n Dose direction duration can be derived from the start and end dates if no other information is available. \u003Cbr clear=\"none\"/\u003E \n When sharing Dose duration direction, the following examples are provided to clarify definitions for two of the coded text items which appear similar. In both cases, these directions are not an absolute instruction. They are: \u003Cbr clear=\"none\"/\u003E \n •‘continue medication indefinitely’ - ongoing treatment planned for example when starting daily aspirin or a statin. There will be circumstances where you would stop them such as a GI bleed. \u003Cbr clear=\"none\"/\u003E \n • ‘do not discontinue’ refers to medication where suddenly stopping could be dangerous, for example the abrupt withdrawal of long-term steroids. \u003Cbr clear=\"none\"/\u003E \n The medication change cluster and medications discontinued cluster both derive from discharge standards to ensure clarity of what medications had changed or been stopped in hospital. They are retained in the core information standard as they may still be useful to professionals in understanding previous medications. \u003Cbr clear=\"none\"/\u003E \n The Medical devices element is for medical devices that cannot be prescribed and do not have representation in the NHS dictionary of medicines and medical devices (dm+d). Whilst medical devices that can be prescribed in primary care are generally well represented in dm+d, there are other kinds of devices used in hospital care which may not be so this section provides for this. \u003Cbr clear=\"none\"/\u003E \n ", "description": "Medications and medical devices", "concept": [ { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Medication item entry", "description": "All medications and devices that can be prescribed to be entered via this Medication item entry. Handles details of continuation / addition / amendment of admission medications.", "concept": [ { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Medication item cluster", "description": "Medication item cluster", "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": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Location", "description": "The location where the medication or the medical device was prescribed.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for location", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://www.datadictionary.nhs.uk/data_dictionary/attributes/o/org/organisation_code_de.asp?shownav=1\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n ", "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": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Performing professional", "description": "The professional who prescribed the medication or medical device.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the professional.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc", "valueSets": "FHIR value set :- \u003Ca class=\"\" href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobroletype\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the professional.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Speciality", "description": "The specialty of the professional e.g. physiotherapy, oncology, mental health etc", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The name of the organisation the professional works for." }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the professional", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK phone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Medication prescribed by", "description": "The type of organisation responsible for authorising and issuing the medication e.g. GP \u003Cbr clear=\"none\"/\u003E \n ", "valueSets": "FHIR value set : - \u003Ca href=\"https://simplifier.net/hl7fhirukcoreprofiler4-dstu/ukcore-medicationprescribingagency\" target=\"\" title=\"\"\u003E Medication prescribing agency\u003C/a\u003E \n " }, { "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": "Medication trade family", "description": "The trade family or brand of the medication prescribed.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for medication trade family or brand.", "valueSets": "SNOMED CT: - 999000641000001107 | National Health Service dictionary of medicines and devices trade family group 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": "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": "SNOMED CT: - ^999000781000001107 | National Health Service dictionary of medicines and devices dose form simple reference set (foundation metadata concept) | \u003Cbr clear=\"none\"/\u003E \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": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Quantity supplied", "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": "Unit of measure", "description": "Unit of measure of quantity supplied", "valueSets": "UCUM code" } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date supplied", "description": "The date/time the medication was supplied.", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Route", "description": "The route by which the medication is administered e.g. oral, IM, IV", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for route", "valueSets": "SNOMED CT: - ^999000051000001100 |ePrescribing route of administration 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": "Site", "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": "SNOMED CT: - <442083009 | Anatomical or acquired body structure (body structure) | \u003Cbr clear=\"none\"/\u003E \n " }, { "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": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Method", "description": "The technique or method by which the medication is to be administered.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for method", "valueSets": "SNOMED CT : - ^999000041000001103 | ePrescribing method 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 coded text available", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Over the counter medication flag", "description": "Indicates if the medication or device is acquired without a prescription i.e. got by the person over the counter", "valueSets": "Flag : - Yes or No", "valueDomain": [ { "type": "boolean" } ] }, { "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": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Dose type", "description": "The kind of rate or dose specified ", "valueSets": "Calculated or ordered", "valueDomain": [ { "type": "boolean" } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Structured dose amount", "description": "A structural representation of dose amount, e.g. 20mg or 2 tablets. This element will generally only be used when persisting data within systems with 'parsable dose directions' being used to exchange the same information between systems. As per FHIR Dose Syntax Implementation Guidance (NHS Digital): \u003Ca class=\"\" href=\"https://simplifier.net/guide/DoseSyntaxImplementationGuidanceforFHIRR4/Home\" target=\"\" title=\"\"\u003Ehttps://simplifier.net/guide/DoseSyntaxImplementationGuidanceforFHIRR4/Home\u003C/a\u003E \n ", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Dose", "description": "Amount of dose medication .Note that this specifies the quantity of the specified medication, not the quantity for each active ingredient(s). Each ingredient amount can be communicated in the Medication resource. For example, if one wants to communicate that a tablet was 375 mg, where the dose was one tablet, you can use the Medication resource to document that the tablet was comprised of 375 mg of drug XYZ. Alternatively if the dose was 375 mg, then you may only need to use the Medication resource to indicate this was a tablet. If the example were an IV such as dopamine and you wanted to communicate that 400mg of dopamine was mixed in 500 ml of some IV solution, then this would all be communicated in the Medication resource. If the administration is not intended to be instantaneous (rate is present or timing has a duration), this can be specified to convey the total amount to be administered over the period of time as indicated by the schedule e.g. 500 ml in dose, with timing used to convey that this should be done over 4 hours.", "valueSets": "Numeric", "valueDomain": [ { "type": "quantity" } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Rate", "description": "Amount of medication per unit of time. Identifies the speed with which the medication was or will be introduced into the patient. Typically the rate for an infusion e.g. 100 ml per 1 hour or 100 ml/hr. May also be expressed as a rate per unit of time e.g. 500 ml per 2 hours. Other examples: 200 mcg/min or 200 mcg/1 minute; 1 liter/8 hours. Sometimes, a rate can imply duration when expressed as total volume / duration (e.g. 500mL/2 hours implies a duration of 2 hours). However, when rate doesn't imply duration (e.g. 250mL/hour), then the timing.repeat.duration is needed to convey the infuse over time period.", "valueSets": "Numeric", "valueDomain": [ { "type": "decimal" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Structured dose timing", "description": "A slot containing a structural, computable representation of dose timing and maximum dose. This element will generally only be used when persisting data within systems with 'parsable dose directions' being used to exchange the same information between systems. As per FHIR Dose Syntax Implementation Guidance (NHS Digital): \u003Ca class=\"\" href=\"https://simplifier.net/guide/DoseSyntaxImplementationGuidanceforFHIRR4/Home\" target=\"\" title=\"\"\u003Ehttps://simplifier.net/guide/DoseSyntaxImplementationGuidanceforFHIRR4/Home\u003C/a\u003E \n ", "valueSets": "Numeric", "valueDomain": [ { "type": "quantity" } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Dose direction duration", "description": "Recommendation of the time period for which the medication should be continued, including direction not to discontinue. As per FHIR Dose Syntax Implementation Guidance (NHS Digital): \u003Ca class=\"\" href=\"https://simplifier.net/guide/DoseSyntaxImplementationGuidanceforFHIRR4/Home\" target=\"\" title=\"\"\u003Ehttps://simplifier.net/guide/DoseSyntaxImplementationGuidanceforFHIRR4/Home\u003C/a\u003E \n ", "valueSets": "Numeric", "valueDomain": [ { "type": "quantity" } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Dose directions description", "description": "Describes the entire medication dosage and administration directions including dose quantity and medication frequency and optionally duration e.g. “1 tablet at night\" or “2mg at 10pm”.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Maxdoseperperiod", "description": "The maximum total quantity of a therapeutic substance that may be administered to a subject over the period of time. For example, 1000mg in 24 hours.", "valueSets": "Numeric", "valueDomain": [ { "type": "quantity" } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Maxdoseperadministration", "description": "The maximum total quantity of a therapeutic substance that may be administered to a subject per administration.", "valueSets": "Numeric", "valueDomain": [ { "type": "quantity" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Repeat medication", "description": "Is the medication prescribed to be repeated", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Number of repeat prescriptions", "description": "The number of repeated prescriptions", "valueSets": "Numeric", "valueDomain": [ { "type": "decimal" } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Review date", "description": "Date to review the repeat medication prescribed to the person", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMD" } ] } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Additional instructions", "description": "Allows for: requirements for adherence support, e.g. compliance aids, prompts and packaging requirements, additional information about specific medicines e.g. where specific brand required, person requirements, e.g. unable to swallow tablets.", "valueSets": "FHIR value set : - \u003Ca href=\"http://hl7.org/fhir/stu3/valueset-additional-instruction-codes.html\" target=\"\" title=\"\"\u003EAdditional instruction\u003C/a\u003E \n " }, { "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": "Course status", "description": "The status of this prescription.", "valueSets": "FHIR value set : - \u003Ca class=\"\" href=\"https://www.hl7.org/fhir/valueset-medication-statement-status.html\" target=\"\" title=\"\"\u003EMedication status\u003C/a\u003E \n \u003Cul/\u003E \n " }, { "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": "Start date/time", "description": "The date and/or time that the medication course should begin.", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "End date/time", "description": "The date and/or time that the medication course should finish.", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Link to indication record", "description": "A link to the record which contains the indication for this medication order.", "valueSets": "Free text with URL", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Comment/recommendation", "description": "Suggestions about duration and/or review, ongoing monitoring requirements, advice on starting, discontinuing or changing medication. Additional comment or recommendation about the medication course e.g. 'Patient named supply', 'unlicensed medication', 'Foreign brand' or monitoring recommendations", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Medication change summary cluster", "description": "Records the changes made to medication.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Status", "description": "The nature of any change made to the medication.", "valueSets": "FHIR value set : \u003Ca href=\"https://www.hl7.org/fhir/valueset-medication-statement-status.html\" target=\"\" title=\"\"\u003EMedication status\u003C/a\u003E \n \u003Cul/\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Indication", "description": "Reason for change in medication, e.g. sub-therapeutic dose, person intolerant.", "valueSets": "\n \u003Ctable class=\"detail spaced\" width=\"100%\" style=\"font-family: Arial, Helvetica, Geneva, sans-serif; font-size: 12px; max-width: 100%; background-image: initial; background-position: initial; background-size: initial; background-repeat: initial; background-attachment: initial; background-origin: initial; background-clip: initial; color: rgb(51, 51, 51);\"\u003E\n \u003Ctbody\u003E\n \u003Ctr\u003E\n \u003Ctd colspan=\"3\" rowspan=\"1\" style=\"vertical-align: top;\"\u003E\n \u003Cdiv class=\"xforms-control xforms-output xforms-mediatype-text-html xforms-mediatype-text\" id=\"xf-895≡xf-1239\" style=\"display: inline; zoom: 1;\"\u003E\n \u003Cdiv class=\"xforms-output-output\" id=\"xf-895≡xf-1239≡≡c\" style=\"zoom: 1;\"\u003ESNOMED CT:- ^1127601000000107 | Healthcare matters simple reference set (foundation metadata concept) |\u003C/div\u003E\n \u003C/div\u003E\n \u003C/td\u003E\n \u003C/tr\u003E\n \u003C/tbody\u003E\n \u003C/table\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date of change", "description": "The date of the change - addition, or amendment", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Description of amendment", "description": "Where a change is made to the medication i.e. one drug stopped and another started or eg dose, frequency or route is changed.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person completing record", "description": "Details of the person completing the record.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The organisational role of the person completing record.", "valueSets": "FHIR value set :- \u003Ca href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobrole\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Specialty", "description": "The main specialty of the person completing the record.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The organisation the person completing the record works for.", "valueSets": "\n \u003Cspan style=\"color: rgb(51, 51, 51); font-family: Arial, Helvetica, Geneva, sans-serif; font-size: 12px;\"\u003ENHS data dictionary : - \u003C/span\u003E \n \u003Ca href=\"https://www.datadictionary.nhs.uk/supporting_information/organisation_data_service.html\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date completed", "description": "The date and time the record was completed.", "valueSets": "Date and time.", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the person completing the record. \u003Cbr clear=\"none\"/\u003E \n ", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK telephone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Medical devices entry", "description": "Medical devices", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Medical device", "description": "Any medical device that isn't prescribed.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Comments", "description": "Any information regarding the medical device.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Medication discontinued entry", "description": "Medication discontinued entry", "concept": [ { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name of discontinued medication", "description": "The name of the medication or medical device being discontinued", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for medication name", "valueSets": "\n \u003Cdiv\u003E\n \u003Ctable class=\"detail spaced\" width=\"100%\" style=\"font-family: Arial, Helvetica, Geneva, sans-serif; font-size: 12px; max-width: 100%; background-image: initial; background-position: initial; background-size: initial; background-repeat: initial; background-attachment: initial; background-origin: initial; background-clip: initial; color: rgb(51, 51, 51);\"\u003E\n \u003Ctbody\u003E\n \u003Ctr\u003E\n \u003Ctd colspan=\"3\" rowspan=\"1\" style=\"vertical-align: top;\"\u003E\n \u003Cdiv class=\"xforms-control xforms-output xforms-mediatype-text-html xforms-mediatype-text\" id=\"xf-895≡xf-1239\" style=\"display: inline; zoom: 1;\"\u003E\n \u003Cdiv class=\"xforms-output-output\" id=\"xf-895≡xf-1239≡≡c\" style=\"zoom: 1;\"\u003Edm+d:- any code from the VTM, VMP, AMP, VMPP and AMPP concept classes\u003C/div\u003E\n \u003C/div\u003E\n \u003C/td\u003E\n \u003C/tr\u003E\n \u003C/tbody\u003E\n \u003C/table\u003E\n \u003C/div\u003E \n \u003Cdiv/\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "description": "Amount of vaccine administered.", "valueSets": "Free text", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "150" } ] } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Status", "description": "The status of any change made to the medication. MUST CONTAIN STOPPED.", "valueSets": "FHIR value set: - \u003Ca href=\"https://www.hl7.org/fhir/valueset-medication-statement-status.html\" target=\"\" title=\"\"\u003EMedication status\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Indication", "description": "The clinical indication for any changes in medication status", "valueSets": "\n \u003Ctable class=\"detail spaced\" width=\"100%\" style=\"font-family: Arial, Helvetica, Geneva, sans-serif; font-size: 12px; max-width: 100%; background-image: initial; background-position: initial; background-size: initial; background-repeat: initial; background-attachment: initial; background-origin: initial; background-clip: initial; color: rgb(51, 51, 51);\"\u003E\n \u003Ctbody\u003E\n \u003Ctr\u003E\n \u003Ctd colspan=\"3\" rowspan=\"1\" style=\"vertical-align: top;\"\u003E\n \u003Cdiv class=\"xforms-control xforms-output xforms-mediatype-text-html xforms-mediatype-text\" id=\"xf-895≡xf-1239\" style=\"display: inline; zoom: 1;\"\u003E\n \u003Cdiv class=\"xforms-output-output\" id=\"xf-895≡xf-1239≡≡c\" style=\"zoom: 1;\"\u003ESNOMED CT:- ^1127601000000107 | Healthcare matters simple reference set (foundation metadata concept) |\u003C/div\u003E\n \u003C/div\u003E\n \u003C/td\u003E\n \u003C/tr\u003E\n \u003C/tbody\u003E\n \u003C/table\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date of change", "description": "The date of the discontinuation", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Comment", "description": "Any additional comment about the discontinuation or amendment.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Equipment and adaptations", "description": "Details of equipment/asset (or modifications) that the Local Authority has provided to the patient.", "concept": [ { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "name": "Equipment record entry", "description": "This is a equipment record entry. There may be 1 to many record entries under a section.", "concept": [ { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Equipment name", "description": "The name of the equipment (e.g. 'Keysafe', 'Handrail' 'Lifeline Alarm', etc.)", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Coded value", "description": "The coded value for equipment name", "valueSets": "SNOMED CT" }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "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": "Date", "description": "\n \u003Cbr clear=\"none\"/\u003E The date the equipment was issued.", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Comment", "description": "Any further details about the equipment, e.g. position of handrail(s) within the person's home", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Plan and requested actions", "implementationGuidance": "This is the treatment plan for the treating team or clinician and any actions requested. This plan should make clear who is expected to take responsibility for actions following an encounter, for example the person receiving care or their carer; the GP or another heath care professional. For example, follow up renal function test to be arranged by the GP within two weeks of appointment. \u003Cbr clear=\"none\"/\u003E \n Shared decision-making principles should apply to the development of the plan and where the person’s opinions differ, this should be included under ‘Agreed with the person or their legitimate person representative’ which will include both the aspects of the plan the person (or their representative) agree with and the aspects they disagree with. \u003Cbr clear=\"none\"/\u003E \n The section would allow for the recording of planned investigations, procedures and treatment for the person’s identified conditions and priorities. \u003Cbr clear=\"none\"/\u003E \n This is not a care plan it is a plan for specific actions to be carried out as a result of an encounter. \u003Cbr clear=\"none\"/\u003E \n ", "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.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date", "description": "The date on which the plan and requested actions were prepared.", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Performing professional", "description": "The professional who prepared the plan and requested actions.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the professional.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc", "valueSets": "FHIR value set :- \u003Ca class=\"\" href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobroletype\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the professional.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Speciality", "description": "The specialty of the professional e.g. physiotherapy, oncology, mental health etc", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The name of the organisation the professional works for." }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the professional", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK phone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Location", "description": "The location where the plan and requested actions were prepared.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for location", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://www.datadictionary.nhs.uk/data_dictionary/attributes/o/org/organisation_code_de.asp?shownav=1\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n ", "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": "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’s 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": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Actions for person or their carer", "description": "For each action the following should be identified:outcome expectations, including person’s 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": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Agreed with the person or their legitimate representative", "description": "Indicates whether the person or their legitimate representative has agreed the entire plan or individual aspects of treatment, expected outcomes, risks and alternative treatments. A record of the agreement of the decisions made.", "valueSets": "Free text", "valueDomain": [ { "type": "text" } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Outcome of plan and requested actions", "description": "The details of the outcome of the plan and requested actions.", "valueSets": "Free text.", "valueDomain": [ { "type": "text" } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person completing record", "description": "Details of the person completing the record.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The organisational role of the person completing record.", "valueSets": "FHIR value set :- \u003Ca href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobrole\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Specialty", "description": "The main specialty of the person completing the record.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The organisation the person completing the record works for.", "valueSets": "\n \u003Cspan style=\"color: rgb(51, 51, 51); font-family: Arial, Helvetica, Geneva, sans-serif; font-size: 12px;\"\u003ENHS data dictionary : - \u003C/span\u003E \n \u003Ca href=\"https://www.datadictionary.nhs.uk/supporting_information/organisation_data_service.html\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date completed", "description": "The date and time the record was completed.", "valueSets": "Date and time.", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the person completing the record. \u003Cbr clear=\"none\"/\u003E \n ", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK telephone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Care and support plan", "implementationGuidance": "It should be possible to restrict access to the care and support plan in most cases based on the individual’s consent preferences. However, a data controller may choose to release all or part of the record for legitimate reasons, for example when a person using services is unable to give consent. \u003Cbr clear=\"none\"/\u003E \n •It should be possible to add attachments or hyperlinks in care and support plans to provide guidance, learning materials, explanatory notes, etc. The date/time of the hyperlink/addition should be included. \u003Cbr clear=\"none\"/\u003E \n •It should be possible to add comments to the plan and to sections in the plan, for example. to identify progress towards a goal (which should have a formal mechanism associated for capturing information). It should also be possible to comment on actions undertaken or suggest changes to actions. Note that adding comments to a plan is not the same as having a dialogue with others involved in the care and support planning process. Separate functionality, e.g. secure messaging would be required for this. \u003Cbr clear=\"none\"/\u003E \n ", "description": "This records the decisions reached during conversation between the individual and health and care professional about future plans and also records progress.", "concept": [ { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Strengths", "implementationGuidance": "Definition: Any strengths and assets the person has (i.e. things a person is good at or enjoys doing) relating to their goals and hopes about their health and well-being For example, ‘able to participate in leisure activities’ such as a sport in order to improve health and wellbeing by losing weight. \u003Cbr clear=\"none\"/\u003E \n ", "description": "Any strengths and assets the person has relating to their goals and hopes about their health and well-being.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value ", "description": "The coded value associated with the person's strengths. Could be derived from the assessment of the person e.g. 300738008 |Able to participate in leisure activities (finding)| \u003Cbr clear=\"none\"/\u003E \n \u003Cdiv\u003E\n \u003Cspan style=\"color: rgb(255, 255, 255); font-family: "Segoe UI", system-ui, "Apple Color Emoji", "Segoe UI Emoji", sans-serif; font-size: 14px;\"\u003E\n \u003Cbr clear=\"none\"/\u003E\n \u003C/span\u003E\n \u003C/div\u003E \n ", "valueSets": "SNOMED CT : - 1127601000000107 | Healthcare matters simple reference set (foundation metadata concept) |" }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "description": "Any supplementary or personalised information that relates to the person's strengths.", "valueSets": "Free text", "valueDomain": [ { "type": "text" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Needs, concerns or problems", "implementationGuidance": "Needs are defined as health or care deficits identified by the person with their carer(s) or professionals and are the motivations/indications for healthcare activities. Examples of needs could be (e.g.) ‘to dress myself’; ‘to better understand what my various medications are for’; ‘to reduce pain in my knees’. \u003Cbr clear=\"none\"/\u003E \n •Concerns are gathered information to support continuity of care for a person. Concerns can include biological, psychological or social concerns. They may include things the person or carer is concerned about. For example, a person’s concern may be ‘the quality of social housing’; a professional’s concern could be ‘high blood pressure’ \u003Cbr clear=\"none\"/\u003E \n •Problems are defined as: A condition that needs addressing and is important for every professional to know about when seeing a person. Problems may include diagnoses (e.g. COPD; diabetes), symptoms (e.g. joint pain; breathlessness), disabilities (e.g. sensory impairments; amputations), health, social and behavioural issues. Problems recorded here may link to the problem list held in a shared care record or GP system for a person using services. \u003Cbr clear=\"none\"/\u003E \n •Goals and hopes are defined as: The overall goals, hopes, aims or targets that the person has. Including anything that the person wants to achieve that relates to their future health and wellbeing. Each goal may include a description of why it is important to the person. Goals may also be ranked in order of importance or priority to the person. For example, ‘weight loss’; smoking cessation’; ‘reducing alcohol intake’; ‘increased sleep’. ‘Goals’ tends to be historically a more medically-used term, whereas ‘hopes’ is used more widely in social care settings. \u003Cbr clear=\"none\"/\u003E \n It should be possible to include tables (e.g. weekly schedule), diagrams or images (e.g. to illustrate how a person has made progress towards a goal) as well as video and audio clips (i.e. as a communication tool for individuals with complex accessibility requirements). \u003Cbr clear=\"none\"/\u003E \n •It should be possible to prioritise goals, indicating the importance of each goal to the person (e.g. a scale 1 to 10). \u003Cbr clear=\"none\"/\u003E \n •Each action may also have an associated additional indicator showing how confident the person is to carry it out (e.g. a scale from 1 to 10). \u003Cbr clear=\"none\"/\u003E \n •The care and support plan should be structured in a way that supports digital information exchange, with separate sections for strengths, needs and problems which can be linked to specific goals. \u003Cbr clear=\"none\"/\u003E \n •Of particular importance is the link between needs in a care plan and related goals. Each goal must link to specific needs, as well as any actions associated with it. Goals may also have related outcomes. \u003Cbr clear=\"none\"/\u003E \n •The sections associated with goals and actions that are the focus of specific care professionals should be interoperable with the care plan that professional uses for their day to day work. \u003Cbr clear=\"none\"/\u003E \n Updates to the care and support plan section may include: \u003Cbr clear=\"none\"/\u003E \n •Add, edit or archive strengths, needs, concerns or problems. If a strength/need/concern becomes more or less important, then goals may need to be changed, as will associated actions. \u003Cbr clear=\"none\"/\u003E \n •Add, edit or archive goals. When a goal is archived it should be possible to also archive the actions associated with it. If the actions are still valid it should be possible to attach them to another goal. \u003Cbr clear=\"none\"/\u003E \n •Add, edit or archive actions. Once an action has been completed (i.e. status updated to indicate it has been completed), it should be possible to archive it from the care and support plan. It should be removed from the current active view of the plan, but available to view in previous versions of the plan. \u003Cbr clear=\"none\"/\u003E \n •Recording outcomes related to goals. Once a goal has been achieved, it should be possible to archive it from the care and support plan, so that it is removed from the view of the current plan, but available to view in previous versions of the care and support plan. \u003Cbr clear=\"none\"/\u003E \n ", "description": "Details of the person needs, concerns or problems \u003Cbr clear=\"none\"/\u003E \n ", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value associated with the person's needs, concerns or problems.", "valueSets": "SNOMED CT : - \u003Ca class=\"\" href=\"https://termbrowser.nhs.uk/?perspective=full&conceptId1=1127581000000103&edition=uk-edition&release=&server=https://termbrowser.nhs.uk/sct-browser-api/snomed&langRefset=999001261000000100,999000691000001104\" target=\"\" title=\"\" style=\"\"\u003E^1127581000000103 |Health issues simple reference set|\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "description": "\n \u003Ctable class=\"detail spaced\" width=\"100%\" style=\"font-family: Arial, Helvetica, Geneva, sans-serif; font-size: 12px; max-width: 100%; background-image: initial; background-position: initial; background-size: initial; background-repeat: initial; background-attachment: initial; background-origin: initial; background-clip: initial; color: rgb(51, 51, 51);\"\u003E\n \u003Ctbody\u003E\n \u003Ctr\u003E\n \u003Ctd colspan=\"3\" rowspan=\"1\" style=\"vertical-align: top;\"\u003E\n \u003Cdiv class=\"xforms-control xforms-output xforms-mediatype-text-html xforms-mediatype-text\" id=\"xf-895≡xf-1189\" style=\"display: inline; zoom: 1;\"\u003E\n \u003Cdiv class=\"xforms-output-output\" id=\"xf-895≡xf-1189≡≡c\" style=\"zoom: 1;\"\u003EAny supplementary or personalised information that relates to the person's needs, concerns and problems.\u003C/div\u003E\n \u003C/div\u003E\n \u003C/td\u003E\n \u003C/tr\u003E\n \u003C/tbody\u003E\n \u003C/table\u003E \n ", "valueSets": "Free text ", "valueDomain": [ { "type": "text" } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Goals and hopes", "description": "\n \u003Ctable class=\"detail spaced\" width=\"100%\" style=\"font-family: Arial, Helvetica, Geneva, sans-serif; font-size: 12px; max-width: 100%; background-image: initial; background-position: initial; background-size: initial; background-repeat: initial; background-attachment: initial; background-origin: initial; background-clip: initial; color: rgb(51, 51, 51);\"\u003E\n \u003Ctbody\u003E\n \u003Ctr\u003E\n \u003Ctd colspan=\"3\" rowspan=\"1\" style=\"vertical-align: top;\"\u003E\n \u003Cdiv class=\"xforms-control xforms-output xforms-mediatype-text-html xforms-mediatype-text\" id=\"xf-895≡xf-1189\" style=\"display: inline; zoom: 1;\"\u003E\n \u003Cdiv class=\"xforms-output-output\" id=\"xf-895≡xf-1189≡≡c\" style=\"zoom: 1;\"\u003EThe overall goals, hopes, aims or targets that the person has. Including anything that the person wants to achieve that relates to their future health and wellbeing. Each goal may include a description of why it is important to the person. Goals may also be ranked in order of importance or priority to the person.\u003C/div\u003E\n \u003C/div\u003E\n \u003C/td\u003E\n \u003C/tr\u003E\n \u003C/tbody\u003E\n \u003C/table\u003E \n ", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value associated with the person's goals, aim's and hopes. e.g. 999002111000000103 |Occupational therapy goals simple reference set (foundation metadata concept)|", "valueSets": "SNOMED CT : - 413350009|Finding with explicit context|: 246090004|Associated finding|=300798006 |Able to participate in sporting activities (finding)|, 408729009|Finding context|=410518001|Goal|" }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text ", "description": "Any supplementary and personalised information relating to the person's goals, aims and hopes.", "valueSets": "Free text", "valueDomain": [ { "type": "text" } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Goal importance score", "description": "Assessment of the person's motivations to achieve this goal, how important the goal is to the person on a scale of 1-10.", "valueSets": "Numeric scale 1 - 10", "valueDomain": [ { "type": "decimal" } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Actions and activities", "description": "Actions or activities the person or others plan to take to achieve the person's goals and the resources required to do this. \u003Cp/\u003E \n ", "concept": [ { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "What", "description": "What the action is and how it is to be carried out?", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for the action. \u003Ctable class=\"detail spaced\" width=\"100%\" style=\"font-family: Arial, Helvetica, Geneva, sans-serif; font-size: 12px; max-width: 100%; background-image: initial; background-position: initial; background-size: initial; background-repeat: initial; background-attachment: initial; background-origin: initial; background-clip: initial; color: rgb(51, 51, 51);\"\u003E\n \u003Ctbody\u003E\n \u003Ctr\u003E\n \u003Ctd colspan=\"3\" rowspan=\"1\" style=\"vertical-align: top;\"\u003E\n \u003Cdiv class=\"xforms-control xforms-output xforms-mediatype-text-html xforms-mediatype-text\" id=\"xf-895≡xf-1189\" style=\"display: inline; zoom: 1;\"\u003E\n \u003Cdiv class=\"xforms-output-output\" id=\"xf-895≡xf-1189≡≡c\" style=\"zoom: 1;\"\u003E\n \u003Cbr clear=\"none\"/\u003E\n \u003C/div\u003E\n \u003C/div\u003E\n \u003C/td\u003E\n \u003C/tr\u003E\n \u003C/tbody\u003E\n \u003C/table\u003E \n ", "valueSets": "SNOMED CT : - << \u003Ca class=\"\" href=\"https://termbrowser.nhs.uk/?perspective=full&conceptId1=71388002&edition=uk-edition&release=&server=https://termbrowser.nhs.uk/sct-browser-api/snomed&langRefset=999001261000000100,999000691000001104\" target=\"\" title=\"\"\u003E71388002\u003C/a\u003E |Procedure| OR << \u003Ca class=\"\" href=\"https://termbrowser.nhs.uk/?perspective=full&conceptId1=129125009&edition=uk-edition&release=&server=https://termbrowser.nhs.uk/sct-browser-api/snomed&langRefset=999001261000000100,999000691000001104\" target=\"\" title=\"\"\u003E129125009\u003C/a\u003E |Procedure with explicit context|" }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "description": "Any supplementary and personalised information for the action.", "valueSets": "Free text", "valueDomain": [ { "type": "text" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Who", "description": "Name and role (e.g. person, carer, GP, OT, etc.) of the person, or a team, carrying out the proposed action, and, if relevant where action should take place.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the professional or person carrying out the proposed action.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "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 : - \u003Ca href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003Esdsjobrole\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Team", "description": "The name of the team.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "35" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the professional (e.g. telephone number, email address etc.).", "valueSets": "Free text", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "When", "description": "Planned date, time, or interval, as relevant", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Suggested strategies", "description": "Suggested strategies for potential problems.", "valueSets": "Free text.", "valueDomain": [ { "type": "text" } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Status", "description": "The status of the action or activity e.g. in progress, done, refused", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for the person's activity status", "valueSets": "SNOMED CT : - ^999000081000000105 | Care planning action context values simple reference set (foundation metadata concept) |" }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "description": "Any supplementary or personalised information for the person's activity status", "valueSets": "Free text", "valueDomain": [ { "type": "text" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Confidence", "description": "How confident the person feels to carry out the action associated to the goal.", "valueSets": "Numeric score 1 - 10", "valueDomain": [ { "type": "decimal" } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date last updated", "description": "Date when action/activity record was last updated", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Review date", "description": "When the action evaluation needs to be reviewed. SNOMED CT tag : - 425268008 | Review of care plan (procedure) |", "valueSets": "Date and time.", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YM" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Stage goal", "description": "Details of the person's stage goals", "concept": [ { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Stage goal", "description": "A specific sub-goal that is related to the overall goal as agreed by the person in collaboration with a professional.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded expression associated with the person's stage goal.", "valueSets": "SNOMED CT : - 413350009|Finding with explicit context|: 246090004|Associated finding|=300798006 |Able to participate in sporting activities (finding)|, 408729009|Finding context|=410518001|Goal|" }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "description": "Any supplementary or personalised information regarding the person's stage goal.", "valueSets": "Free text", "valueDomain": [ { "type": "text" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Outcome", "description": "The outcome of the stage goal", "valueSets": "\n \u003Cbr clear=\"none\"/\u003E \n \u003Cdiv\u003E\n \u003Cspan style=\"color: rgb(255, 255, 255); font-family: "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 12px;\"\u003E\n \u003Cbr clear=\"none\"/\u003E\n \u003C/span\u003E\n \u003C/div\u003E \n ", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value ", "description": "The coded value for the person's stage goal outcome.", "valueSets": "SNOMED CT: - ^1127601000000107 |Healthcare matters simple reference set (foundation metadata concept)| " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "description": "Any supplementary and personalised information relating to the person's outcome.", "valueSets": "Free text", "valueDomain": [ { "type": "text" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Goal status", "description": "The status associated with the person's stage goal", "valueSets": "SNOMED CT: - ^999000091000000107 | Care planning goal context values simple reference set (foundation metadata concept) |" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Outcomes", "description": "Outcomes of each of the person’s goals, aims and targets. Includes comments recorded by the person, date and status.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value associated with the person's overall goal outcome", "valueSets": "SNOMED CT: - \u003Cspan style=\"color: rgb(51, 51, 51); font-family: Arial, Helvetica, Geneva, sans-serif; font-size: 12px;\"\u003E^1127601000000107 |Healthcare matters simple reference set (foundation metadata concept)| \u003C/span\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "description": "\n \u003Cspan style=\"color: rgb(51, 51, 51); font-family: Arial, Helvetica, Geneva, sans-serif; font-size: 12px;\"\u003EAny supplementary and personalised information relating to the person's goal outcome.\u003C/span\u003E \n ", "valueSets": "Free text", "valueDomain": [ { "type": "text" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Goal status", "description": "The status associated with the person's overall goal.", "valueSets": "SNOMED CT: - ^999000091000000107 | Care planning goal context values simple reference set (foundation metadata concept) |" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Agreed with person or legitimate representative", "implementationGuidance": "•Agreement of the plan with the person (or representative) should be recorded. If agreement cannot be obtained the reason for this should be documented. \u003Cbr clear=\"none\"/\u003E \n •Where a person has been unable to agree, due to, for example, lacking mental capacity, actions should be undertaken to maximise capacity and the plan should demonstrate how a person’s rights will be promoted. If a person is unable to consent, a mental capacity assessment should be attempted, and if there is no legal representative a best interest decision made. \u003Cbr clear=\"none\"/\u003E \n ", "description": "Indicates whether the plan was discussed and agreed with the person or legitimate representative.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person or legitimate representative", "description": "Indicates whether the plan was discussed and agreed with the person or legitimate representative", "valueSets": "Person or legitimate representative ", "valueDomain": [ { "type": "boolean" } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person full name", "description": "The full name of the person in text representation.", "valueSets": "NHS data dictionary :- \u003Ca class=\"\" href=\"https://datadictionary.nhs.uk/data_elements/person_full_name.html?hl=person%2Cname\" target=\"\" title=\"\"\u003EPatient full name\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The role the professional has in relation to the person.", "valueSets": "FHIR value set : - \u003Ca class=\"\" href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003Esdsjobrole\u003C/a\u003E \n " } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Care funding source", "implementationGuidance": "In health and social care there may be different sources of funding (e.g. personal budget/personal health budgets) to meet the aims and goals of the person. The ‘Care Funding Source’ section should only detail the source of the funding so as to support easy resolution where a question about funding arises. The information should not include the details of the funding, which will be held in separate documents. \u003Cbr clear=\"none\"/\u003E \n ", "description": "A reference to the funding source and any conditions or limitations associated.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The organisation code of the care funding source", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://www.datadictionary.nhs.uk/attributes/organisation_code.html?hl=organisation%2Cdata%2Cservice\" target=\"\" title=\"\"\u003Eorganisation data service\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text ", "description": "Any further information for the person's care funding source e.g. self funded", "valueSets": "Free text ", "valueDomain": [ { "type": "text" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date this plan was last updated", "implementationGuidance": "This information should be automatically retrievable from the system. \u003Cbr clear=\"none\"/\u003E \n ", "description": "This is a record of the date that this care and support plan was last updated.", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Other care planning documents", "description": "Reference other care planning documents, including the type, location and date. \u003Cbr clear=\"none\"/\u003E \n \u003Cbr clear=\"none\"/\u003E This may include condition-specific plans, advance care plans, end of life care plan, etc.", "valueSets": "Free text.", "valueDomain": [ { "type": "text" } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Planned review date/interval", "description": "This is the date/interval when this information will next be reviewed. SNOMED CT tag : - 425268008 | Review of care plan (procedure) |", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime" } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Responsibility for review", "description": "This is a record of who has responsibility for arranging review of this information. \u003Cbr clear=\"none\"/\u003E \n ", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the professional with responsibility for the care of the person.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker, key worker, care home manager, care coordinator, LA hospital liaison person, care home contact, hospital clinician, Independent Mental Capacity Advocate (IMCA) etc", "valueSets": "FHIR value set : - \u003Ca href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobrole\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the professional (e.g. telephone number, email address etc.).", "valueSets": "Free text", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Location", "description": "The location where the care and support plan was prepared.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for location", "valueSets": "NHS data dictionary: - \u003Ca href=\"https://www.datadictionary.nhs.uk/data_dictionary/attributes/o/org/organisation_code_de.asp?shownav=1\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n ", "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 coded text available", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Performing professional", "description": "The professional who prepared the care and support plan.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the professional.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc", "valueSets": "FHIR value set :- \u003Ca class=\"\" href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobroletype\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the professional.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Speciality", "description": "The specialty of the professional e.g. physiotherapy, oncology, mental health etc", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The name of the organisation the professional works for." }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the professional", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK phone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person completing record", "description": "Details of the person completing the record.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The organisational role of the person completing record.", "valueSets": "FHIR value set :- \u003Ca href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobrole\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Specialty", "description": "The main specialty of the person completing the record.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The organisation the person completing the record works for.", "valueSets": "\n \u003Cspan style=\"color: rgb(51, 51, 51); font-family: Arial, Helvetica, Geneva, sans-serif; font-size: 12px;\"\u003ENHS data dictionary : - \u003C/span\u003E \n \u003Ca href=\"https://www.datadictionary.nhs.uk/supporting_information/organisation_data_service.html\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date completed", "description": "The date and time the record was completed.", "valueSets": "Date and time.", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the person completing the record. \u003Cbr clear=\"none\"/\u003E \n ", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK telephone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Contingency/safety plans", "implementationGuidance": "Contingency/safety plans are known by other terms depending on care setting. In mental health for example, ‘safety plans’ is a commonly understood term while medically these are more commonly known as ‘Contingency plans’. \u003Cbr clear=\"none\"/\u003E \n •Not everyone who has a care and support plan will need a contingency/safety (also known as crisis/emergency/escalation/advance/anticipatory) plan. See the Glossary (section 5) which includes alternative names for care planning concepts in the standard. \u003Cbr clear=\"none\"/\u003E \n •This plan is for those people who have specific and predictable risks associated with their health and wellbeing. It describes how disruptions to the care and support plan should be addressed. \u003Cbr clear=\"none\"/\u003E \n •There may be a number of different contingency/safety plans to manage different aspects of health and wellbeing, e.g. diabetes, respiratory, mental health, substance misuse, etc. The plan may cover different scenarios, e.g. mild disruption/issues, through to more severe. \u003Cbr clear=\"none\"/\u003E \n •It must be possible to create a contingency/safety plan at any time when the individual and those providing care and support identify a need for such a plan. \u003Cbr clear=\"none\"/\u003E \n •Contingency/safety plans must be subject to or as a result of an assessment. \u003Cbr clear=\"none\"/\u003E \n •Contingency/safety plans may include end of life care planning elements. These only form part of an initial conversation and a full end of life care plan should be included separately as an end of life care document. \u003Cbr clear=\"none\"/\u003E \n •The ‘Coping Strategies’ element should include details of all coping strategies used in free text. Any tools used to carry out the coping strategy should be included here. \u003Cbr clear=\"none\"/\u003E \n •Coping strategies may need to be regularly updated as it may depend on the stage of recovery the person is at. \u003Cbr clear=\"none\"/\u003E \n ", "description": "\n \u003Cspan style=\"font-size:10.0pt;line-height:107%; font-family:"Arial",sans-serif;mso-fareast-font-family:Calibri;mso-fareast-theme-font: minor-latin;mso-ansi-language:EN-GB;mso-fareast-language:EN-US;mso-bidi-language: AR-SA\"\u003EThese are the things to do and people to contact, should an individual’s\nhealth or other circumstances get worse for safety.\u003C/span\u003E \n \u003Cbr clear=\"none\"/\u003E \n ", "concept": [ { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Trigger factors", "description": "Signs to watch out for that may indicate a significant change in health or other circumstances e.g. feeling agitated", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The trigger that leads to instigation of a significant change in health or other circumstances. \u003Cbr clear=\"none\"/\u003E \n ", "valueSets": "SNOMED CT: - ^1127581000000103 | Health issues simple reference set (foundation metadata concept) |" }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "description": "Any free text associated with the person's trigger factor", "valueSets": "Free text", "valueDomain": [ { "type": "text" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contingency plan name", "description": "When the action evaluation needs to be reviewed. ", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for the type of care plan", "valueSets": "SNOMED CT: - 999001471000000108 | Care plan type simple reference set (foundation metadata concept) |" }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "description": "Free text if no coded value is available.", "valueSets": "Free text", "valueDomain": [ { "type": "text" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "What should happen", "description": "Guidance on specific actions or interventions that may be required or should be avoided in specific situations. This may include circumstances where action needs to be taken if a carer is unable to care for the person. A statement of suggested actions. Usually expressed as: in the event of X do Y.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value ", "description": "The coded value for what should happen", "valueSets": "\n \u003Ctable class=\"detail spaced\" width=\"100%\" style=\"font-family: Arial, Helvetica, Geneva, sans-serif; font-size: 12px; max-width: 100%; background-image: initial; background-position: initial; background-size: initial; background-repeat: initial; background-attachment: initial; background-origin: initial; background-clip: initial; color: rgb(51, 51, 51);\"\u003E\n \u003Ctbody\u003E\n \u003Ctr\u003E\n \u003Ctd colspan=\"3\" rowspan=\"1\" style=\"vertical-align: top;\"\u003E\n \u003Cdiv class=\"xforms-control xforms-output xforms-mediatype-text-html xforms-mediatype-text\" id=\"xf-895≡xf-1239\" style=\"display: inline; zoom: 1;\"\u003E\n \u003Cdiv class=\"xforms-output-output\" id=\"xf-895≡xf-1239≡≡c\" style=\"zoom: 1;\"\u003ESNOMED CT : - <<\u003Ca class=\"\" href=\"https://termbrowser.nhs.uk/?perspective=full&conceptId1=71388002&edition=uk-edition&release=&server=https://termbrowser.nhs.uk/sct-browser-api/snomed&langRefset=999001261000000100,999000691000001104\" target=\"\" title=\"\" style=\"color: rgb(0, 136, 204); text-decoration-line: none;\"\u003E71388002\u003C/a\u003E |Procedure| OR <<\u003Ca class=\"\" href=\"https://termbrowser.nhs.uk/?perspective=full&conceptId1=129125009&edition=uk-edition&release=&server=https://termbrowser.nhs.uk/sct-browser-api/snomed&langRefset=999001261000000100,999000691000001104\" target=\"\" title=\"\" style=\"color: rgb(0, 136, 204); text-decoration-line: none;\"\u003E129125009\u003C/a\u003E |Procedure with explicit context|\u003C/div\u003E\n \u003C/div\u003E\n \u003C/td\u003E\n \u003C/tr\u003E\n \u003C/tbody\u003E\n \u003C/table\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "description": "Any supplementary or personalised information regarding what should happen", "valueSets": "\n \u003Cspan style=\"color: rgb(51, 51, 51); font-family: Arial, Helvetica, Geneva, sans-serif; font-size: 12px;\"\u003EFree text\u003C/span\u003E \n ", "valueDomain": [ { "type": "text" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Who should be contacted", "description": "Who should be contacted in the event of significant problems or deterioration in health or wellbeing. e.g. name, role and contact details.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the professional with responsibility for the care of the person.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker, key worker, care home manager, care coordinator, LA hospital liaison person, care home contact, hospital clinician, Independent Mental Capacity Advocate (IMCA) etc", "valueSets": "FHIR value set : - \u003Ca href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobrole\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the personal contact (e.g. telephone number, email address etc.)", "valueSets": "Free Text", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Agreed with person or legitimate representative", "description": "Indicates whether the plan was discussed and agreed with the person or legitimate representative.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person or legitimate representative", "description": "Indicates whether the plan was discussed and agreed with the person or legitimate representative", "valueSets": "Person or legitimate representative ", "valueDomain": [ { "type": "boolean" } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person full name", "description": "The full name of the person in text representation.", "valueSets": "NHS data dictionary :- \u003Ca class=\"\" href=\"https://datadictionary.nhs.uk/data_elements/person_full_name.html?hl=person%2Cname\" target=\"\" title=\"\"\u003EPatient full name\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The role the professional has in relation to the person.", "valueSets": "FHIR value set : - \u003Ca class=\"\" href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003Esdsjobrole\u003C/a\u003E \n " } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date this plan was last updated", "description": "The date that this contingency plan was last updated.", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Planned review date/interval", "description": "This is the date/interval when this contingency plan will next be reviewed. SNOMED CT tag : - 425268008 | Review of care plan (procedure) |", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Responsibility for review", "description": "This is who has responsibility for arranging review of this information. \u003Cbr clear=\"none\"/\u003E \n ", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the professional with responsibility for the care of the person.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker, key worker, care home manager, care coordinator, LA hospital liaison person, care home contact, hospital clinician, Independent Mental Capacity Advocate (IMCA) etc", "valueSets": "FHIR value set : - \u003Ca href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobrole\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the professional (e.g. telephone number, email address etc.).", "valueSets": "Free text", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Coping strategies", "description": "Details of coping strategies used", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coping strategy", "description": "The coping strategies are defined as thoughts and behaviours that people use to manage the internal and external demands of situations that are appraised as stressful. This should also include a record of any tools used to carry out the coping strategy.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Start date", "description": "The date when the coping strategy started", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "End date", "description": "The date when the coping strategy ended", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Relapse indicators / early warning signs", "description": "Details of the relapse indicators for the person. These may also be called 'early warning signs'", "valueSets": "\n \u003Cbr clear=\"none\"/\u003E \n \u003Cdiv id=\"home-descriptions-fh-cd1_canvas\" style=\"box-sizing: border-box; color: rgb(255, 255, 255); font-family: "Helvetica Neue", Helvetica, Arial, sans-serif; font-size: 12px;\"/\u003E \n ", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for relapse indicators/early warning signs", "valueSets": "SNOMED CT : - ^1127601000000107 | Healthcare matters simple reference set (foundation metadata concept) |" }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "description": "Any supplementary or personalised information regarding the relapse indicators/early warning signs", "valueSets": "Free text", "valueDomain": [ { "type": "text" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Advance statement", "description": "Written requests and preferences made by a person with capacity conveying their wishes, beliefs and values for their future care should they lose capacity.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date", "description": "The date when the advanced statements was made.", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Location", "description": "The location where the advanced statement was made.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for location", "valueSets": "NHS data dictionary: - \u003Ca href=\"https://www.datadictionary.nhs.uk/data_dictionary/attributes/o/org/organisation_code_de.asp?shownav=1\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n ", "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": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Advance statement", "description": "Does the person have an advance statement.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for advance statement", "valueSets": "SNOMED CT: - 816281000000101 | Has advance statement (Mental Capacity Act 2005) (finding) |" }, { "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": "Location of document", "description": "The location of where the advanced statement is held.", "valueSets": "Free text or URL", "valueDomain": [ { "type": "text" } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Performing professional", "description": "The professional who made the advance statement.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the professional.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc", "valueSets": "FHIR value set :- \u003Ca class=\"\" href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobroletype\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the professional.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Speciality", "description": "The specialty of the professional e.g. physiotherapy, oncology, mental health etc", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The name of the organisation the professional works for." }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the professional", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK phone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person completing record", "description": "Details of the person completing the record.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The organisational role of the person completing record.", "valueSets": "FHIR value set :- \u003Ca href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobrole\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Specialty", "description": "The main specialty of the person completing the record.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The organisation the person completing the record works for.", "valueSets": "\n \u003Cspan style=\"color: rgb(51, 51, 51); font-family: Arial, Helvetica, Geneva, sans-serif; font-size: 12px;\"\u003ENHS data dictionary : - \u003C/span\u003E \n \u003Ca href=\"https://www.datadictionary.nhs.uk/supporting_information/organisation_data_service.html\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date completed", "description": "The date and time the record was completed.", "valueSets": "Date and time.", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the person completing the record. \u003Cbr clear=\"none\"/\u003E \n ", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK telephone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Anticipatory medicines/equipment", "description": "Medicines or equipment available that may be required in specific situations and their location. A statement regarding the availability or location of the anticipatory medicines/equipment. SNOMED CT Tag : - 871021000000106 | Prescription of palliative care anticipatory medication (procedure) |", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Location", "description": "The location where the contingency plan was prepared.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for location", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://www.datadictionary.nhs.uk/data_dictionary/attributes/o/org/organisation_code_de.asp?shownav=1\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n ", "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": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Performing professional", "description": "The professional who prepared the contingency plans.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the professional.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc", "valueSets": "FHIR value set :- \u003Ca class=\"\" href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobroletype\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the professional.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Speciality", "description": "The specialty of the professional e.g. physiotherapy, oncology, mental health etc", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The name of the organisation the professional works for." }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the professional", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK phone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person completing record", "description": "Details of the person completing the record.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The organisational role of the person completing record.", "valueSets": "FHIR value set :- \u003Ca href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobrole\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Specialty", "description": "The main specialty of the person completing the record.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The organisation the person completing the record works for.", "valueSets": "\n \u003Cspan style=\"color: rgb(51, 51, 51); font-family: Arial, Helvetica, Geneva, sans-serif; font-size: 12px;\"\u003ENHS data dictionary : - \u003C/span\u003E \n \u003Ca href=\"https://www.datadictionary.nhs.uk/supporting_information/organisation_data_service.html\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date completed", "description": "The date and time the record was completed.", "valueSets": "Date and time.", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the person completing the record. \u003Cbr clear=\"none\"/\u003E \n ", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK telephone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Additional support plans", "implementationGuidance": "It must be possible to hold additional supporting plans, which may be linked to the care and support plan where the individual or care professional decides that the information should be available to others. Examples of additional supporting plans: asthma plan, mental health plan, tissue viability plan, nutrition plan, falls prevention plan, hospital or other service transfer of care plan, etc. \u003Cbr clear=\"none\"/\u003E \n •The format of additional supporting plans will vary according to the type of plan. Some may be structured and coded, some may include diagrams or images. \u003Cbr clear=\"none\"/\u003E \n •Additional supporting plans should be available for others to view, but will only be created, updated and ended by the service creating the plan. These may be made available on the National record Locator Service (NRL) in PDF format. \u003Cbr clear=\"none\"/\u003E \n •When an additional supporting plan is updated a new version of the plan may be linked to the care and support plan, again at the discretion of the individual or care professional. \u003Cbr clear=\"none\"/\u003E \n •Educational and health care plans are produced for people with neurodevelopmental conditions and apply up to the age of 25. However, they transition into adult services earlier so it is important to note that this plan may exist at the same time as a care and support plan. \u003Cbr clear=\"none\"/\u003E \n ", "description": "Additional support plans", "concept": [ { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Additional support plan name", "description": "The name of the particular additional supporting plan, e.g. dieticians plan, wound management plan, discharge management plan and behaviour support plan.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for the type of care plan", "valueSets": "SNOMED CT: - 999001471000000108 | Care plan type simple reference set (foundation metadata concept) |" }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "description": "Free text if no coded value is available", "valueSets": "Free text", "valueDomain": [ { "type": "text" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Additional support plan content", "description": "This is the content of any additional care and support plan which the person and/or care professional consider should be shared with others providing care and support. May be structured in different ways, e.g. tables, diagrams, images. This is the content of any additional care and support plan which the individual and/or care professional consider should be shared with others providing care and support. It should be structured as recommended for the care and support plan and if contains additional detail, it may be referenced here.", "valueSets": "Free text", "valueDomain": [ { "type": "text" } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Planned review date/interval", "description": "This is the date/interval when this information will next be reviewed. SNOMED CT tag : - 425268008 | Review of care plan (procedure) |", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime" } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Responsibility for review", "description": "This is a record of who has responsibility for arranging review of this information. Should include their name, role and contact details.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the professional with responsibility for the care of the person.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker, key worker, care home manager, care coordinator, LA hospital liaison person, care home contact, hospital clinician, Independent Mental Capacity Advocate (IMCA) etc", "valueSets": "FHIR value set : - \u003Ca href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobrole\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the professional (e.g. telephone number, email address etc.).", "valueSets": "Free text", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date this plan was last updated", "description": "This is a record of the date that this information was last updated.", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Location", "description": "The location where the additional support plan was prepared.", "valueSets": "ODS code or free text", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for location", "valueSets": "NHS data dictionary:- \u003Ca href=\"https://www.datadictionary.nhs.uk/data_dictionary/attributes/o/org/organisation_code_de.asp?shownav=1\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n ", "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": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Performing professional", "description": "The professional who prepared the additional support plan.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the professional.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc", "valueSets": "FHIR value set :- \u003Ca class=\"\" href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobroletype\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the professional.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Speciality", "description": "The specialty of the professional e.g. physiotherapy, oncology, mental health etc", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The name of the organisation the professional works for." }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the professional", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK phone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person completing record", "description": "Details of the person completing the record.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The organisational role of the person completing record.", "valueSets": "FHIR value set :- \u003Ca href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobrole\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Specialty", "description": "The main specialty of the person completing the record.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The organisation the person completing the record works for.", "valueSets": "\n \u003Cspan style=\"color: rgb(51, 51, 51); font-family: Arial, Helvetica, Geneva, sans-serif; font-size: 12px;\"\u003ENHS data dictionary : - \u003C/span\u003E \n \u003Ca href=\"https://www.datadictionary.nhs.uk/supporting_information/organisation_data_service.html\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date completed", "description": "The date and time the record was completed.", "valueSets": "Date and time.", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the person completing the record. \u003Cbr clear=\"none\"/\u003E \n ", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK telephone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "End of life care", "implementationGuidance": "This section contains information that would be expected in an end of life care plan that does not appear elsewhere in the core information standard. This is not a representation of an end of life care plan as it would be expected to include this information as well as information covered elsewhere in the standard. The information included in the standard is consistent with the end of life minimum dataset and SCCI1580. However, PRSB recognises that there is work to do to develop a nationally agreed information standard for an end of life care plan. \u003Cbr clear=\"none\"/\u003E \n ", "description": "Information relating to end of life care. \u003Cbr clear=\"none\"/\u003E \n \u003Cbr clear=\"none\"/\u003E N.B. This is not an end of life care plan but contains information that would be found in an end of life care plan.", "concept": [ { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Cardio-pulmonary resuscitation (CPR) decision", "description": "Whether a decision has been made, the decision, who made the decision, the date of decision, date for review and location of documentation. Where the person or their family member/carer have not been informed of the clinical decision please state the reason why.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date", "description": "The date when the cardio-pulmonary resuscitation decision was made.", "valueSets": "Date and time.", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Location", "description": "The location where the cardio-pulmonary resuscitation decision was made.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for location", "valueSets": "NHS data dictionary: - \u003Ca href=\"https://www.datadictionary.nhs.uk/data_dictionary/attributes/o/org/organisation_code_de.asp?shownav=1\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n ", "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 coded text available", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Cardio-pulmonary resuscitation (CPR) decision", "description": "The cardio-pulmonary resuscitation (CPR) decision.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for CPR decision or DNACPR", "valueSets": "SNOMED CT: - 450475007 | For cardiopulmonary resuscitation (finding) |, 450476008 | Not for cardiopulmonary resuscitation (finding) |" }, { "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": "Date for review", "description": "The date for review of CPR decision.", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Location of document", "description": "The location of the CPR decision document", "valueSets": "Free text or URL", "valueDomain": [ { "type": "text" } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Performing professional", "description": "The professional who made the cardio-pulmonary resuscitation decision.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the professional.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc", "valueSets": "FHIR value set :- \u003Ca class=\"\" href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobroletype\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the professional.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Speciality", "description": "The specialty of the professional e.g. physiotherapy, oncology, mental health etc", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The name of the organisation the professional works for." }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the professional", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK phone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person completing record", "description": "Details of the person completing the record.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The organisational role of the person completing record.", "valueSets": "FHIR value set :- \u003Ca href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobrole\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Specialty", "description": "The main specialty of the person completing the record.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The organisation the person completing the record works for.", "valueSets": "\n \u003Cspan style=\"color: rgb(51, 51, 51); font-family: Arial, Helvetica, Geneva, sans-serif; font-size: 12px;\"\u003ENHS data dictionary : - \u003C/span\u003E \n \u003Ca href=\"https://www.datadictionary.nhs.uk/supporting_information/organisation_data_service.html\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date completed", "description": "The date and time the record was completed.", "valueSets": "Date and time.", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the person completing the record. \u003Cbr clear=\"none\"/\u003E \n ", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK telephone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Estimated prognosis", "description": "Details of the persons estimated prognosis", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date", "description": "The date when the estimated prognosis was made.", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Location", "description": "The location where the estimated prognosis was made.", "valueSets": "ODS code or free text", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for location", "valueSets": "NHS data dictionary: - \u003Ca\u003EOrganisation data service\u003C/a\u003E \n ", "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 coded text available", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Estimated prognosis", "description": "Where a person is terminally ill this is a clinical judgment indicating the anticipated period of time until death e.g. last days, weeks, months or year of life.", "valueSets": "Free text", "valueDomain": [ { "type": "text" } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Performing professional", "description": "The professional who made the estimated prognosis.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the professional.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc", "valueSets": "FHIR value set :- \u003Ca class=\"\" href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobroletype\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the professional.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Speciality", "description": "The specialty of the professional e.g. physiotherapy, oncology, mental health etc", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The name of the organisation the professional works for." }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the professional", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK phone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person completing record", "description": "Details of the person completing the record.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The organisational role of the person completing record.", "valueSets": "FHIR value set :- \u003Ca href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobrole\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Specialty", "description": "The main specialty of the person completing the record.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The organisation the person completing the record works for.", "valueSets": "\n \u003Cspan style=\"color: rgb(51, 51, 51); font-family: Arial, Helvetica, Geneva, sans-serif; font-size: 12px;\"\u003ENHS data dictionary : - \u003C/span\u003E \n \u003Ca href=\"https://www.datadictionary.nhs.uk/supporting_information/organisation_data_service.html\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date completed", "description": "The date and time the record was completed.", "valueSets": "Date and time.", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the person completing the record. \u003Cbr clear=\"none\"/\u003E \n ", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK telephone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Awareness of prognosis", "description": "Details of the persons awareness of prognosis", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date", "description": "The date when the assessment of the level of awareness of the prognosis was made.", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Location", "description": "The location where the assessment of the level of awareness of the prognosis was made.", "valueSets": "ODS code and free text", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for location", "valueSets": "NHS data dictionary: - \u003Ca href=\"https://www.datadictionary.nhs.uk/data_dictionary/attributes/o/org/organisation_code_de.asp?shownav=1\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n ", "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": "Awareness of prognosis", "description": "Description of the level of awareness the person and or their carer/family has regarding their estimated prognosis.", "valueSets": "Free text", "valueDomain": [ { "type": "text" } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Performing professional", "description": "The professional who made the assessment of the level of awareness of the prognosis.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the professional.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc", "valueSets": "FHIR value set :- \u003Ca class=\"\" href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobroletype\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the professional.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Speciality", "description": "The specialty of the professional e.g. physiotherapy, oncology, mental health etc", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The name of the organisation the professional works for." }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the professional", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK phone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person completing record", "description": "Details of the person completing the record.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The organisational role of the person completing record.", "valueSets": "FHIR value set :- \u003Ca href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobrole\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Specialty", "description": "The main specialty of the person completing the record.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The organisation the person completing the record works for.", "valueSets": "\n \u003Cspan style=\"color: rgb(51, 51, 51); font-family: Arial, Helvetica, Geneva, sans-serif; font-size: 12px;\"\u003ENHS data dictionary : - \u003C/span\u003E \n \u003Ca href=\"https://www.datadictionary.nhs.uk/supporting_information/organisation_data_service.html\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date completed", "description": "The date and time the record was completed.", "valueSets": "Date and time.", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the person completing the record. \u003Cbr clear=\"none\"/\u003E \n ", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK telephone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Priorities of care", "description": "The priorities agreed between the person and their health/care team, where the person has capacity: To get better; please consider all treatment to prolong life. To achieve a balance between getting better and ensuring good quality of life; please consider selected treatments. Comfort; please consider all treatments aimed at symptom control.", "valueSets": "Free text", "valueDomain": [ { "type": "text" } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Anticipatory actions", "description": "Details of the person's anticipatory actions", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date", "description": "The date when the anticipatory actions were identified.", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Location", "description": "The location where the anticipatory actions were identified.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for location", "valueSets": "NHS data dictionary: - \u003Ca href=\"https://www.datadictionary.nhs.uk/data_dictionary/attributes/o/org/organisation_code_de.asp?shownav=1\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n ", "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 coded text available", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Anticipatory actions", "description": "Guidance on specific interventions or actions that may be required or should be avoided in specific situations. A statement of anticipatory actions. Usually expressed as: in the event of X do Y.", "valueSets": "Free text", "valueDomain": [ { "type": "string", "property": [ { "minLength": "3", "maxLength": "5" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Performing professional", "description": "The professional who identified the anticipatory actions.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the professional.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc", "valueSets": "FHIR value set :- \u003Ca class=\"\" href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobroletype\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the professional.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Speciality", "description": "The specialty of the professional e.g. physiotherapy, oncology, mental health etc", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The name of the organisation the professional works for." }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the professional", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK phone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person completing record", "description": "Details of the person completing the record.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The organisational role of the person completing record.", "valueSets": "FHIR value set :- \u003Ca href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobrole\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Specialty", "description": "The main specialty of the person completing the record.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The organisation the person completing the record works for.", "valueSets": "\n \u003Cspan style=\"color: rgb(51, 51, 51); font-family: Arial, Helvetica, Geneva, sans-serif; font-size: 12px;\"\u003ENHS data dictionary : - \u003C/span\u003E \n \u003Ca href=\"https://www.datadictionary.nhs.uk/supporting_information/organisation_data_service.html\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date completed", "description": "The date and time the record was completed.", "valueSets": "Date and time.", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the person completing the record. \u003Cbr clear=\"none\"/\u003E \n ", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK telephone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Anticipatory medicines/equipment", "description": "Details of the persons availability or location regarding their anticipatory medicines/equipment.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date", "description": "The date when the statement regarding anticipatory medicines/equipment was made.", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Location", "description": "The location where the statement regarding anticipatory medicines/equipment was made.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for location", "valueSets": "NHS data dictionary: - \u003Ca href=\"https://www.datadictionary.nhs.uk/data_dictionary/attributes/o/org/organisation_code_de.asp?shownav=1\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n ", "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 coded text available", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Anticipatory medicines/equipment", "description": "A statement regarding the availability or location of the anticipatory medicines/equipment.", "valueSets": "Free text", "valueDomain": [ { "type": "text" } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Performing professional", "description": "The professional who made the statement regarding anticipatory medicines/equipment was made.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the professional.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc", "valueSets": "FHIR value set :- \u003Ca class=\"\" href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobroletype\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the professional.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Speciality", "description": "The specialty of the professional e.g. physiotherapy, oncology, mental health etc", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The name of the organisation the professional works for." }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the professional", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK phone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person completing record", "description": "Details of the person completing the record.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The organisational role of the person completing record.", "valueSets": "FHIR value set :- \u003Ca href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobrole\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Specialty", "description": "The main specialty of the person completing the record.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The organisation the person completing the record works for.", "valueSets": "\n \u003Cspan style=\"color: rgb(51, 51, 51); font-family: Arial, Helvetica, Geneva, sans-serif; font-size: 12px;\"\u003ENHS data dictionary : - \u003C/span\u003E \n \u003Ca href=\"https://www.datadictionary.nhs.uk/supporting_information/organisation_data_service.html\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date completed", "description": "The date and time the record was completed.", "valueSets": "Date and time.", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the person completing the record. \u003Cbr clear=\"none\"/\u003E \n ", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK telephone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Preferred place of death", "description": "Details of the person's preferred place of death", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date", "description": "The date when the preferred place of death was identified.", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Location", "description": "The location where the preferred place of death was identified.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for location", "valueSets": "NHS data dictionary: - \u003Ca href=\"https://www.datadictionary.nhs.uk/data_dictionary/attributes/o/org/organisation_code_de.asp?shownav=1\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n ", "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": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Preferred place of death 1st", "description": "The preferences that a person has identified as their preferred place to die.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name of the place", "description": "The name of the preferred place of death", "valueSets": "Free text", "valueDomain": [ { "type": "text" } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Type of place", "description": "The type of preferred place of death", "valueSets": "SCC11580 code : - 10: Hospital (Acute/Community/Other)20: Private residence21: Patient's own home22: Other private residence (eg relatives home, carers home)30: Hospice (inpatient specialist palliative care)40: Care Home50: Other (free text eg secure and detained settings)517111000000103, Preferred place of death: patient unable to express preference 517131000000106, Preferred place of death: discussion not appropriate766391000000108, Preferred place of death: patient declined discussion517161000000101, Preferred place of death: patient undecided" } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Preferred place of death 2nd", "description": "The preferences that a person has identified as their preferred place to die.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name of the place", "description": "The name of the preferred place of death", "valueSets": "Free text", "valueDomain": [ { "type": "text" } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Type of place", "description": "The type of preferred place of death", "valueSets": "SCC11580 code : - 10: Hospital (Acute/Community/Other)20: Private residence21: Patient's own home22: Other private residence (eg relatives home, carers home)30: Hospice (inpatient specialist palliative care)40: Care Home50: Other (free text eg secure and detained settings)517111000000103, Preferred place of death: patient unable to express preference 517131000000106, Preferred place of death: discussion not appropriate766391000000108, Preferred place of death: patient declined discussion517161000000101, Preferred place of death: patient undecided" } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Performing professional", "description": "The professional who identified the preferred place of death.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the professional.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc", "valueSets": "FHIR value set :- \u003Ca class=\"\" href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobroletype\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the professional.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Speciality", "description": "The specialty of the professional e.g. physiotherapy, oncology, mental health etc", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The name of the organisation the professional works for." }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the professional", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK phone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person completing record", "description": "Details of the person completing the record.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The organisational role of the person completing record.", "valueSets": "FHIR value set :- \u003Ca href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobrole\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Specialty", "description": "The main specialty of the person completing the record.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The organisation the person completing the record works for.", "valueSets": "\n \u003Cspan style=\"color: rgb(51, 51, 51); font-family: Arial, Helvetica, Geneva, sans-serif; font-size: 12px;\"\u003ENHS data dictionary : - \u003C/span\u003E \n \u003Ca href=\"https://www.datadictionary.nhs.uk/supporting_information/organisation_data_service.html\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date completed", "description": "The date and time the record was completed.", "valueSets": "Date and time.", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the person completing the record. \u003Cbr clear=\"none\"/\u003E \n ", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK telephone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Preferred place of care", "description": "Details of the persons preferred place of care", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date", "description": "The date when the preferred place of care was identified.", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Location", "description": "The location where the preferred place of care was identified.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for location", "valueSets": "NHS data dictionary: - \u003Ca href=\"https://www.datadictionary.nhs.uk/data_dictionary/attributes/o/org/organisation_code_de.asp?shownav=1\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n ", "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": "Preferred place of care", "description": "The preferences that the person has identified as their preferred place to receive care.", "valueSets": "Free text", "valueDomain": [ { "type": "text" } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Performing professional", "description": "The professional who identified the preferred place of care.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the professional.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc", "valueSets": "FHIR value set :- \u003Ca class=\"\" href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobroletype\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the professional.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Speciality", "description": "The specialty of the professional e.g. physiotherapy, oncology, mental health etc", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The name of the organisation the professional works for." }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the professional", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK phone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person completing record", "description": "Details of the person completing the record.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The organisational role of the person completing record.", "valueSets": "FHIR value set :- \u003Ca href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobrole\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Specialty", "description": "The main specialty of the person completing the record.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The organisation the person completing the record works for.", "valueSets": "\n \u003Cspan style=\"color: rgb(51, 51, 51); font-family: Arial, Helvetica, Geneva, sans-serif; font-size: 12px;\"\u003ENHS data dictionary : - \u003C/span\u003E \n \u003Ca href=\"https://www.datadictionary.nhs.uk/supporting_information/organisation_data_service.html\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date completed", "description": "The date and time the record was completed.", "valueSets": "Date and time.", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the person completing the record. \u003Cbr clear=\"none\"/\u003E \n ", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK telephone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Documents (including correspondence, audio and images)", "implementationGuidance": "This section includes details for documents and images. It includes the metadata that is required for the document or image and a link to the actual document or image. When displayed in a record, documents and images should be organised logically in date order. Local implementations will need to determine the best logical groupings for use here. \u003Cbr clear=\"none\"/\u003E \n A specific cluster is included for images as these are a special case where there is a document (e.g. a KOS document) with information about the image and often produced by the machine or imaging system, and a specific set of additional information (such as event code list and format code). Note that this document is separate from the investigation report which provides the results or interpretation of the imaging. For images the performing professional will be the person performing the imaging procedure rather than the author. \u003Cbr clear=\"none\"/\u003E \n ", "description": "Details about documents related to the person.", "concept": [ { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "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.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date", "description": "The date and time the document was created.", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Performing professional", "description": "The professional who authored the document.", "valueSets": "Free text.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the professional.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc", "valueSets": "FHIR value set :- \u003Ca class=\"\" href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobroletype\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the professional.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Speciality", "description": "The specialty of the professional e.g. physiotherapy, oncology, mental health etc", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the professional e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The name of the organisation the professional works for." }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the professional", "valueSets": "NHS data dictionary - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK phone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "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", "mro": "R", "name": "Confidentiality", "description": "The code specifying the level of confidentiality of the document.", "valueSets": "\n \u003Cp\u003EFHIR value set : - \u003Ca class=\"\" href=\"https://www.hl7.org/fhir/v3/ConfidentialityClassification/vs.html\" target=\"\" title=\"\"\u003EConfidentiality\u003C/a\u003E\n \u003C/p\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Class", "description": "The document type e.g. report, summary, images, treatment plan, patient preferences, workflow", "valueSets": "Free text.", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Document title", "description": "The title of the document.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Document name", "description": "The name of the document. This should align to the PRSB document naming standard. Where the document is a KOS document this field (designated typeCode) is used to carry the DICOM Imaging procedure: This attribute shall be populated by the XDS-I Imaging Document Source from a code in the Procedure Code Sequence (0008,1032) of the performed procedure with which the document is associated. Values may be found in a suitable DICOM browser", "valueSets": "SNOMED CT: - As per the \u003Ca class=\"\" href=\"https://theprsb.org/wp-content/uploads/2018/11/Clinical-document-indexing-standards_NHS-Scotland.pdf\"\u003Ehttps://theprsb.org/wp-content/uploads/2018/11/Clinical-document-indexing-standards_NHS-Scotland.pdf\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Document MIME type", "description": "MIME type of the document e.g. application, pdf, audio, jpeg", "valueSets": "Free text", "valueDomain": [ { "type": "text" } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person completing record", "description": "Details of the person completing the record.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "70" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The organisational role of the person completing record.", "valueSets": "FHIR value set :- \u003Ca href=\"https://simplifier.net/ukcore/codesystem-ukcore-sdsjobrolename\" target=\"\" title=\"\"\u003ESDSjobrole\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "description": "The grade of the person completing the record.", "valueSets": "Free text.", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Specialty", "description": "The main specialty of the person completing the record.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/activity_treatment_function_code.html?hl=activity%2Ctreatment%2Cfunction%2Ccode\" target=\"\" title=\"\"\u003EActivity treatment function code\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "3" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "description": "The organisation the person completing the record works for.", "valueSets": "\n \u003Cspan style=\"color: rgb(51, 51, 51); font-family: Arial, Helvetica, Geneva, sans-serif; font-size: 12px;\"\u003ENHS data dictionary : - \u003C/span\u003E \n \u003Ca href=\"https://www.datadictionary.nhs.uk/supporting_information/organisation_data_service.html\" target=\"\" title=\"\"\u003EOrganisation data service\u003C/a\u003E \n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "description": "Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.", "valueSets": "NHS data dictionary :- \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/professional_registration_entry_identifier.html\" target=\"\" title=\"\"\u003EProfessional registration identifier\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "32" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date completed", "description": "The date and time the record was completed.", "valueSets": "Date and time.", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "Contact details of the person completing the record. \u003Cbr clear=\"none\"/\u003E \n ", "valueSets": "NHS data dictionary : - \u003Ca href=\"https://datadictionary.nhs.uk/data_elements/uk_telephone_number.html?hl=number\" target=\"\" title=\"\"\u003EUK telephone number\u003C/a\u003E \n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Service", "description": "The high level imaging speciality code e.g. (R-3027B, SRT, “Radiology”)", "valueSets": "SNOMED CT or free text 999000381000000107 |Correspondence care setting type simple reference set (foundation metadata concept)|", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for service", "valueSets": "SNOMED CT :- 1127531000000102 |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": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "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": "Additional information required for images.", "description": "Additional information required for images.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Image procedure", "description": "The procedure used to capture the image", "valueSets": "Free text \u003Cbr clear=\"none\"/\u003E Using DICOM code set \u003Ca class=\"\" href=\"https://dicom.innolitics.com/ciods\"\u003Ehttps://dicom.innolitics.com/ciods\u003C/a\u003E \n ", "valueDomain": [ { "type": "text" } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Image procedure date", "description": "The date and time the image procedure was performed.", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Images", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Image capture date", "description": "The date and time when the image was captured.", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YMDHM" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Image ID", "description": "A unique image identifier generated by the system.", "valueSets": "Free text", "valueDomain": [ { "type": "identifier" } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Image location", "description": "The URL for the image", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Format code", "description": "The format code of the document which provides information on how to display the document.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Event code list", "description": "The type of image (acquisition modality) and the anatomical site imaged.", "valueSets": "DICOM code" }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Comments", "description": "Comments associated with the imaging", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] } ] } ] } ] } ] } ] }