0.3 Amends made after project board and assurance committee approval
0.4 Amends made for publication, frozen as v1.0 final draft for publication
", "concept": [{"type": "group", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "M", "name": "Person demographics", "implamentationGuidance": "The mandatory information in this section is person\u2019s name, date of birth and address. There can be multiple addresses associated with a person including temporary and correspondence addresses. These are stored on the PDS.Details of the person's GP practice.
\n ", "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", "informationType": "Record", "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": "text", "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": "0", "maximumMultiplicity": "1", "mro": "R", "name": "GP practice identifier", "description": "The identifier of the registered GP practice.", "valueSets": "\nDentist organisations can be found on the DOS.\u00a0\u00a0The information will be provided by the person.\u00a0\u00a0Include details of the practice name, address and postcode.
\n ", "description": "Name and address of the person's dental practice.\u00a0", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Dental practice identifier", "description": "The identifier of the dental practice", "valueDomain": [{"type": "string", "property": [{"maxLength": "10"}]}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Individual requirements", "implamentationGuidance": "This is not mandatory for providing care but is deemed as a 'Must have' to support other health and care activities. This section allows for the sharing of any individual requirements the person may have, such as to\n support cognitive impairment or mobility issues. This may relate to special needs and would extend to include a record of reasonable adjustments. Specific disabilities would be included in the \u2019Problem list\u2019 section however the requirements to support the disabilities (e.g. needs wheelchair access, needs large print etc.) would be included in this section. The\n accessible information requirements information would be the most recent requirement rather than a history of requirements.Under the Equality Act 2010, organisations have a legal duty to make changes in their approach or provision to ensure that services are as\n accessible to people with disabilities as they are for everybody else. These changes are called reasonable adjustments.
\nReasonable 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.
\nOther 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\u2019s 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\n the NHS.
\n ", "valueSets": "As 'direct care' is the legal basis for sharing information consent is not mandatory however gaining a persons consent for the capturing and sharing of information for referring on to other services or for sending a PEM to a persons registered GP ensures an individual is fully aware of who will see the information recorded and shared.
", "description": "Legal information captured relating to patient care, such as consent.", "informationType": "Event.Record", "concept": [{"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.", "valueSets": "Free text.", "valueDomain": [{"type": "string"}]}]}, {"type": "group", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "M", "name": "Referral details", "implamentationGuidance": "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 textNHS data dictionary : - Organisation data service
", "valueDomain": [{"type": "string", "property": [{"minLength": "3", "maxLength": "5"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "description": "The contact details of the referrer.", "valueSets": "Free text", "valueDomain": [{"type": "string", "property": [{"maxLength": "70"}]}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Person Referral Reference", "implamentationGuidance": "The aim of this element is for it to be given to the patient by the referrer (Sender) service so they can take it to the service they are referred to (Receiver service), providing a link for the patient between the two services. Additionally, it\u2019s a useful point of reference for the two services should they need to speak to each other about the patient\u2019s care.
BaRS have implemented a mechanism (in FHIR messaging) whereby when the Sender makes a referral request, they receive the human readable reference in the synchronous response. The Sender makes the request, the Receiver accept it and processes into their system and sends back a response to the Sender with the human readable reference to say it was successful.
", "description": "A human-readable reference given to the person to use when contacting or going to the service referred on to. It is generated by the receiving service and supplied to the referrer as part of the Booking and Referral Standard (BaRS) messaging.
Free text
", "valueDomain": [{"type": "string"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Journey ID", "implamentationGuidance": "This reference is to help support tracking of patients/people on multiple referrals through the system.
", "description": "This is a machine-readable reference which the Sender of any initial referral (i.e. it was not sent to them as a referral) generates and includes in their referral request. If the sender is not the initial referrer (i.e. they received a referral) they must include the original reference in their referral.
", "valueSets": "This should be a globally unique identifier (GUID) value. https://learn.microsoft.com/en-us/windows/win32/api/guiddef/ns-guiddef-guid\u00a0
", "valueDomain": [{"type": "string"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Referral type", "description": "An indication of the type of referral (e.g. 'Hospital Discharge Notification to Social Care', 'GP Referral', etc.)", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}, {"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 onlyThe CAS clinician may identify and wish to share a Chief Clinical Concern following a 111 encounter. This section allows for all relevant problems, and issues.\u00a0 This would include disabilities, including learning disabilities, and conditions such as autism where they fall into the above categories i.e.,\n 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.
\n\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, when a patients \u2018presenting complaints or issues\u2019 are indigestion and belching,\n \u2018dyspepsia\u2019 may be deemed the \u2018Chief Complaint\u2019, \u00a0the 111 clinicians \u2018Chief Clinical Concern\u2019 maybe a \u2018gastric ulcer\u2019.\u00a0 Which would require endoscopy, and the subsequent biopsies to confirm the diagnosis of a gastric ulcer.\u00a0 Unconfirmed or excluded diagnoses should not be include in structured coded\u00a0fields but may be included in free text in the comments field.
\u00a0
\n 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.\u00a0 The differential diagnoses should only be included in free text in the comments field, and not in a coded diagnosis field until confirmed\n with confidence.\u00a0 \n \u00a0 \n \nSNOMED CT: - <281694009 |Finding of at risk (finding)|
\u00a0
| \n \n \ndm+d:- any code from the VTM, VMP, AMP, VMPP, AMPP and ingredient concept classes \n |
This is a generic section for recording all types of medication including those prescribed by healthcare professionals and administered by a person (or their carer).
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/.
The free text Dose directions description is the form of dosage direction typically used in UK GP Systems.
Dose direction duration can be derived from the start and end dates if no other information is available.
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:
\u2018continue medication indefinitely\u2019 - 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 (gastrointestinal) bleed.
\u2018do not discontinue\u2019 refers to medication where suddenly stopping could be dangerous, for example the abrupt withdrawal of long-term steroids.
The Medical devices element is for medical devices that cannot (in general) 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.
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:
\u2018continue medication indefinitely\u2019 - 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 (gastrointestinal) bleed.
\u2018do not discontinue\u2019 refers to medication where suddenly stopping could be dangerous, for example the abrupt withdrawal of long-term steroids.
| \n \n \n dm+d:- any code from the VTM, VMP, AMP, VMPP and AMPP concept classes \n | \n
Free text field to be used if no code is available.
", "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: - Medication status \n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Indication", "description": "The clinical indication for any changes in medication status", "valueSets": "