{ "dataset": [ { "name": "_111_pem_for_information", "description": "

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", "implementationGuidance": "The mandatory information in this section is person’s 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.
\n
\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 :- Person given name\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 : - Person family name\n
\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: - Person full name\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: - Person Title\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: - Person suffix\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 :- Person full name\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:- Person birth date\n ", "valueDomain": [ { "type": "date", "property": [ { "timeStampPrecision": "YMD!" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "gender", "implementationGuidance": "This is not mandatory for providing care but is deemed as a 'Must have' to support other activities. Section 22 of the Gender Reassignment Act 2004 makes it an offence to disclose the history of a transgender patient who has had formal gender reassignment under the Act, unless consent has been sought. The exemption of disclosure is for medical professionals involved in direct medical care, but not currently for administrative and non-medical staff. For the full Act, see https://www.legislation.gov.uk/ukpga/2004/7/contents. This risk can be mitigated by appropriate implementation; refer to the 111 Referral clinical safety case report and hazard log. One option is to leave out the “Sex” field but the implications and potential risks of that will need to be considered. The alternative is to ensure the design, including its Information Governance model, reduces this risk to an acceptable level as described in the clinical safety case and hazard log. A further mitigation on implementation could be to record self-expressed gender in the administrative area of systems, and record sex at birth in a separate clinical area, that can only be accessed by medical staff.
\n ", "description": "The person's stated gender.", "valueSets": "NHS data dictionary :- Person stated gender code\n
\n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "1" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "ethnicity", "implementationGuidance": "This is not a mandatory field but is a required field due to it's importance in the care of an individual and understanding la persons individual level of risk based on ethnicity related illness.
\n ", "description": "The ethnicity of the person as specified by the person.", "valueSets": "NHS data dictionary :- Ethnic category\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
SNOMED_CT:- Religion\n
\n
\n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "sex", "implementationGuidance": "The persons phenotypic sex. Determines how the person will be treated clinically The definitions used for sex and gender use the NHS data dictionary definitions to ensure interoperability with other systems. However, we recognise that the definitions used do not reflect today’s more inclusive society. We have provided feedback on this to NHS data dictionary team in NHS Digital who are actively addressing this area, and any updates to the NHS data dictionary will update our standards. Sex and gender data items may cause accidental disclosure of gender reassignment without consent. This is because both fields are included in the demographic model. Having both may show a difference and therefore disclose gender reassignment without consent. It is unlawful to disclose, without consent, a person’s gender reassignment with or without a gender reassignment certificate recognise that the definitions used do not reflect today’s more inclusive society. We have provided feedback on this to NHS data dictionary team in NHS Digital who are actively addressing this area, and any updates to the NHS data dictionary will update our standards
\n ", "description": "The person’s phenotypic sex. Determines how the person will be treated clinically.", "valueSets": "NHS data dictionary: - person phenotypic sex\n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "1" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "nhs_number", "implementationGuidance": "This is not mandatory for providing care but is deemed as a 'Must have' to support other health & care requirements
\n ", "description": "The unique identifier for a person within the NHS in England and Wales.", "valueSets": "NHS data dictionary:- NHS number\n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "10" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "nhs_number_status_indicator", "description": "Provides an indication of the reliability of an NHS Number.", "valueSets": "NHS data dictionary :- NHS Number Code Status Indicator\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
NHS data dictionary: - Local patient identifier(extended), Health and care number (NI\n only), Community health index number (Scotland only)
\n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "20" } ] } ] }, { "type": "group", "minimumMultiplicity": "1", "maximumMultiplicity": "*", "mro": "M", "name": "persons_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
NHS data dictionary :- Address line 1\n
\n
\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
NHS data dictionary :- Address line 2\n
\n
\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
NHS data dictionary : - Address line 3\n
\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
NHS data dictionary : - Address line 4\n
\n
\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 : - Address line 5\n
\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 :- Postcode of usual address\n
\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 :- Address Association Type\n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "1" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "persons_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:- Preferred Contact Method\n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "1" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "persons_telephone_number_details", "description": "The person's telephone number details", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "persons_telephone_number", "description": "The person's telephone number", "valueSets": "NHS data dictionary : - UK telephone number\n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "35" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "persons_telephone_number_type", "description": "The contact type e.g. home, mobile", "valueSets": "FHIR value set: - Contact point use\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": "persons_email_address_details", "description": "Details of the person's email address", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "persons_email_address", "description": "Email address of the person.", "valueSets": "NHS data dictionary:- Contact Email Address\n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "255" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "persons_email_address_type", "description": "\n
The type of email address, home, work.
\n ", "valueSets": "FHIR value set: - Contact point use\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": "\n
Contact details via fax, sms, url.
\n ", "valueSets": "NHS data dictionary:- Communication contact string\n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "255" } ] } ] } ] }, { "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": "Mulitmedia file", "valueDomain": [ { "type": "blob" } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "place_of_birth", "description": "The country of birth of the person.", "valueSets": "NHS data dictionary :- Country code (birth)\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 :- Person marital status\n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "1" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "immigration_status", "implementationGuidance": "Details of the immigration status of the person to be included (e.g. asylum seeker, indefinite leave to remain in the UK). Include start date, end date and any comments
\n ", "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 opted out of automatic organ and/or tissue 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 :- Overseas visitor charging catergory\n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "1" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "gp_practice", "description": "\n

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", "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": "\n
NHS data dictionary : - General medical practice code (patient registration)\n
\n
\n ", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "6" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "gp_opt_out_indicator", "description": "Indication that the person has opted out of registering with a GP.", "valueSets": "SNOMED CT : - 1092961000000104 |Does not wish to register with an NHS general practitioner (finding)| OR 1092941000000100 |Family using private general practitioner (finding)|" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "individual_requirements", "implementationGuidance": "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 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 ’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. The accessible information requirements information would be the most recent requirement rather than a history of requirements.
\n ", "description": "The individual requirements of the person.", "concept": [ { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "reasonable_adjustment", "implementationGuidance": "This is not mandatory for providing care but is deemed as a 'Must have' to support other health and care. This includes an individuals requirement for soft lighting, no noise a quite room etc.
\n ", "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": "1", "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": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "reasonable_adjustment_flag", "description": "

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.

\n

Reasonable 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.

\n

Other 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\n the NHS.

\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
^999002121000000109 |Accessible information - communication support simple reference set (foundation metadata concept)|
^999002151000000104 |Accessible information - requires communication professional simple reference set (foundation metadata concept)|
^999002131000000106 |Accessible information - requires specific contact method simple reference set (foundation metadata concept)|
^999002141000000102 |Accessible information - requires specific information format simple reference set (foundation metadata concept)|
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": "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. 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. Access must be controlled to this information as per SCCI1609: Child Protection - Information Sharing.
\n ", "description": "The safeguarding details of the person.", "concept": [ { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "safeguarding_concerns", "description": "\n
Details of safeguarding concerns.
\n ", "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": "safeguarding_concerns", "description": "Identified safeguarding concerns.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "coded_value", "description": "The coded value for safeguarding concerns", "valueSets": "SNOMED CT : - ^999002381000000108 | Safeguarding issues simple reference set (foundation\n metadata concept) |\n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "free_text", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "R", "name": "referral_details", "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": "persons_input_into_service_selection_flag", "description": "Flag to identify if the person has requested referral to a specific service. ", "valueDomain": [ { "type": "boolean" } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "persons_input_into_service_selection", "description": "The person's requested service, the reason for rejection and comments. ", "concept": [ { "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": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "reason_for_rejection", "description": "The person's reason for rejecting suggested service.", "valueDomain": [ { "type": "string" } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "comment", "description": "The referrer's comments on the person's input into service selection.", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "150" } ] } ] } ] }, { "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": "1", "maximumMultiplicity": "1", "mro": "R", "name": "referrer_details", "implementationGuidance": "Referrer details includes the details of the person making the referral and the service a person is being referred from and to. 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.
\n ", "description": "The details of the referrer that is making the referral or the transfer.
\n
This could be the person, GP surgery, department, specialty, sub-specialty, educational institution, mental health team, care home etc.", "valueSets": "\n

\n ", "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 : - sdsjobrole\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 - Activity treatment function code\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 : - 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": "referred_by_emergency_care", "description": "The details of where the person was referred to emergency care from.", "valueSets": "\n SNOMED CT: - 999002991000000109 | Emergency care attendance source simple reference set (foundation metadata concept) |\n
\n " }, { "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", "implementationGuidance": "

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’s a useful point of reference for the two services should they need to speak to each other about the patient’s 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.

", "valueSets": "

Free text

", "valueDomain": [ { "type": "string" } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "journey_id", "implementationGuidance": "

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

", "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", "implementationGuidance": "\n
\n ", "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
  1. Fax
    2. \n
  2. Phone
    3. \n
  3. Secure Messaging
    4. \n
  4. Secure Email
    5. \n
  5. Letter
    6. \n
  6. NHS E-Referral Service
    7. \n
  7. Self referral
    8. \n
\n " }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "reason_for_referral", "implementationGuidance": "\n The presenting complaints and issues and chief complaint record’s the person reported and referrer perceived needs of the person. ‘Reason for referral’ is used if needed to qualify those presenting complaints or issues or the reason for the choice of referral destination.\n
\n ", "description": "The reason for the referral, e.g. diagnosis, treatment, transfer of care due to relocation, investigation, second opinion, management of the patient (e.g. palliative care), or carer's concerns.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "coded_value", "description": "The coded value for reason for referral", "valueSets": "
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": "urgency_of_referral", "implementationGuidance": "The value set in this use case will be the textual description for the DX Code from the 111 Service, replacing the specified NHS DD Priority Type
\n ", "description": "The details of the urgency of referral", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "urgency", "implementationGuidance": "The value set in this use case will be the textual description for the DX Code from the 111 Service, replacing the specified NHS DD Priority Type.
\n ", "description": "This is the priority of a request for services", "valueSets": "\n
NHS data dictionary : - PRIORITY TYPE
\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": "1", "maximumMultiplicity": "1", "mro": "R", "name": "referral_to", "implementationGuidance": "For the PEM for information the 'referral to ' section is not mandatory as not all 111 encounters lead to a referral.
\n ", "description": "Details of where the referral is to be sent.
\n
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 values set : - ukcorepractitionerrolecode\n
\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": "\n
NHS data dictionary - Activity treatment function code
\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": "\n
NHS data dictionary :- Organisation data service
\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": "1", "maximumMultiplicity": "1", "mro": "M", "name": "presenting_complaints_or_issues", "implementationGuidance": "This section is used in multiple Information Standards and in general terms describes the complaint or issues as perceived by the individual reporting the complaint or issue, including the referrer. A person can have multiple complaints or issues recorded in an Information Standard.
\n
This will be the Symptom Group (SG) or the Symptom Discriminator (SD) code description. This will replace the Chief Complaint code set
\n ", "description": "Presenting complaints or issues", "concept": [ { "type": "group", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "M", "name": "presenting_complaint_or_issue", "description": "The health problem or issue experienced by the person resulting in their attendance. This may include disease state, medical condition, response and reactions to therapies. e.g., blackout, dizziness, chest pain, follow up from admission, falls, a specific procedure, investigation or treatment.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "coded_value", "description": "The coded value for presenting complaint or issue", "valueSets": "SNOMED CT : - ^1127581000000103 |Health issues simple reference\n set|\n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "free_text", "valueSets": "Free text", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "150" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "M", "name": "chief_complaint", "implementationGuidance": "Should a person describe multiple complaints, this allows for the clinician to capture the complaint the clinician regards as the main complaint.
\n
This will be the textual detail from the Symptom Group (SG) and Symptom Discriminator (SD) code description. This will replace Chief Complaint Code set
\n ", "description": "The nature of the person's chief complaint as assessed by the care professional first assessing the person. Only ONE (chief complaint) sent as per the Chief Complaint code set (SNOMED CT).", "property": [ { "p": [ "Event.Record" ] } ], "concept": [ { "type": "item", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "M", "name": "coded_value", "description": "The coded value of the chief complaint", "valueSets": "SNOMED CT: - 991401000000107 | Emergency care presenting complaints or\n issues simple reference set (foundation metadata concept)\n " }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "free_text", "description": "Any free text if no coded value is available", "valueSets": "Free text", "valueDomain": [ { "type": "text" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "person_reported_complaints_or_issues", "implementationGuidance": "Person stated description of the health problems and issues. This may differ from the clinicians impression. This may also be expressed on behalf of the person, eg by parent or carer
\n ", "description": "Person stated description of the health problems and issues. This may differ from the clinicians impression. This may also be expressed on behalf of the person, eg by parent or carer.", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "repeat_caller", "description": "Repeat caller, if the person has called more than twice in 96 hours.", "valueSets": "Yes or no", "valueDomain": [ { "type": "boolean" } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "addtional_information_sources", "implementationGuidance": "As well as specifying the source of information or a link to the source, this can also be used to include local information which might not be available to the referring destination, e.g. Special Patient Notes.
\n ", "description": "The source of additional relevant information about the person e.g. summary care record or link via NRL or copy and paste local record e.g. Special Patient Notes (SPN)", "valueSets": "Free text or url", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "150" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "problem_list", "implementationGuidance": "This section allows for all the Chief Clinical Concern; problems and issues to be recorded. The Referral / PEM should inform the receiver of the main problem(s) / issues that were important during the 111 encounter
\n ", "description": "A summary of the problems that require investigation or treatment.", "concept": [ { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "problem_list_record_entry", "description": "This is a problem list record entry.
\n
There may be 0 to many record entries under problem list.
\n
Each record entry is made up of a number of elements or data items.", "concept": [ { "type": "group", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "R", "name": "problem", "implementationGuidance": "The 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. 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.
\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 ‘presenting complaints or issues’ are indigestion and belching,\n ‘dyspepsia’ may be deemed the ‘Chief Complaint’, the 111 clinicians ‘Chief Clinical Concern’ maybe a ‘gastric ulcer’. Which would require endoscopy, and the subsequent biopsies to confirm the diagnosis of a gastric ulcer.
\n
Unconfirmed or excluded diagnoses should not be include in structured coded 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.
\n ", "description": "A condition which needs addressing and so is important for every professional to know about when seeing the person.
\n
Problems may include diagnoses, symptoms, and social or behavioural issues", "concept": [ { "type": "item", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "R", "name": "coded_value", "implementationGuidance": "SNOMED CT allows the coding of Problems which may also be ‘diagnoses’ or ‘issues’, depending on the context in which they are recorded, some codes may need to be 'qualified' by a number of attributes e.g. grade; severity; distribution; behaviour; laterality etc. e.g. Problem: Migraine Qualifier: SuspectedDue to limitations in how the receiving organisations ingest and present Qualifiers i.e. Not all systems can ingest the 'qualifier' into the receiving system. Qualifiers should not be used when coding an unconfirmed / suspected diagnosis. As this may result in a diagnosis being incorrectly coded in to the individuals EHR.To prevent incorrect coding of a diagnosis in the patients electronic health record it is recommended that any suspected diagnosis should be captured in free text only, until the issue is resolved.
\n ", "description": "The coded value for the problem list.", "valueSets": "
SNOMED CT : - ^1127581000000103 |Health issues simple reference set|
" }, { "type": "item", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "R", "name": "free_text", "implementationGuidance": "Free text field to be used if coding is not available or when the chief clinical concern; problem or issue requires a qualifier i.e. gastric ulcer - 'suspected'
\n ", "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", "implementationGuidance": "This is the date of onset of the chief clinical concern; problem or issues
\n ", "description": "A date or estimated date that the problem began", "valueSets": "Date and time", "valueDomain": [ { "type": "datetime", "property": [ { "timeStampPrecision": "YM" } ] } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "clinical_summary", "implementationGuidance": "A brief summary of the 111 encounter. This may include interpretation of the persons complaints and issues, using the chief complaint and the chief clinical concern. The summary may also list specific action(s). Planned actions will be recorded under ‘plan’.
\n ", "description": "Clinical Summary", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "clinical_narrative", "implementationGuidance": "This is a text field to allow the clinician to explain the persons situation and outcome of the encounter. The clinician may add additional information that they feel is relevant to share with the receiving service / GP
\n ", "description": "A description detailing a patient’s reason for attendance, results from the diagnostic and treatment process.", "valueSets": "Free text", "valueDomain": [ { "type": "text" } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "risks", "description": "Details of any risks related to the person.", "concept": [ { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "risks_record_entry", "description": "This is a risks 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": "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": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "risk", "description": "The risk to the person or others, this includes any risk the person might cause to themselves or to others. e.g. suicide, self harm. ", "valueSets": "\n
\n ", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "coded_value", "description": "The coded value for risk. ", "valueSets": "

SNOMED CT: - <281694009 |Finding of at risk (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": "comment", "description": "Additional details about the risk. ", "valueSets": "Free text", "valueDomain": [ { "type": "string", "property": [ { "maxLength": "150" } ] } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "allergies_and_adverse_reactions", "implementationGuidance": "This is for person reported allergies or adverse reactions which may not be on the persons electronic health record. It is NOT to transfer the person's recorded allergies which the receiver can look up (e.g. via SCR, GP Record or shared care record). The full section has been kept for consistency even if only some of the elements are needed for this use case.
\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.
\n
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 :- Allergy, Intolerance\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
\n
dm+d:- any code from the VTM, VMP, AMP, VMPP, AMPP and ingredient concept classes
\n
\n
SNOMED 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)
" }, { "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": "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) |
" }, { "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 : - Severity\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 : - Certainty\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", "valueSets": "
Free text
", "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": "\n
When the reaction was first experienced i.e this may not be the first time this has happened. May be a date or partial date (e.g. year) or text (e.g. during childhood)
\n ", "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": "medications_and_medical_devices", "implementationGuidance": "

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:

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.

", "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": "group", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "M", "name": "medication_name", "description": "May be generic name or brand name.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "coded_value", "description": "The coded value for medication name", "valueSets": "dm+d:- any code from the VTM, VMP, AMP, VMPP and AMPP concept classes" }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "free_text", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [ { "type": "text", "property": [ { "maxLength": "150" } ] } ] } ] }, { "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "form", "description": "The form of the medication e.g. capsule, drops, tablet, lotion etc.", "concept": [ { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "coded_value", "description": "The coded value for form.", "valueSets": "

SNOMED CT: - ^999000781000001107 | National Health Service dictionary of medicines and devices dose form 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": "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) |
" }, { "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": "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): https://simplifier.net/guide/DoseSyntaxImplementationGuidanceforFHIRR4/Home
", "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\n 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\n 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.\n 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): https://simplifier.net/guide/DoseSyntaxImplementationGuidanceforFHIRR4/Home\n ", "valueSets": "Numeric", "valueDomain": [ { "type": "quantity" } ] }, { "type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "dose_duration_direction", "implementationGuidance": "

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:

", "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): https://simplifier.net/guide/DoseSyntaxImplementationGuidanceforFHIRR4/Home\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": "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 : - Additional instruction\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 : - Medication status\n