For the implementation of this Standard there are a number of 'Must Have' fields as well as the PDS Mandatory fields that are required as part of the NHS E&I Minimum dataset; e.g. gender and ethnicity.
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This section contains the person\u2019s demographic and contact details including key identifiers e.g. name, date of birth, NHS number, address etc.
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\u2022 NHS 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.
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The PDS (Personal Demographics Service) should be used as the source of this information. The mandatory information in this section is person\u2019s name, date of birth. address. There can be multiple addresses associated with a person including temporary and correspondence addresses.\u00a0
\n\n ", "description": "The person's stated gender.", "valueSets": "NHS data dictionary :- Person stated gender code \n\n \n\n
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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\u2019s more inclusive society. We have provided feedback on this to NHS data\n 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\u2019s phenotypic sex. Determines how the person will be treated clinically.", "valueSets": "NHS data dictionary: - person phenotypic sex \n ", "valueDomain": [{"type": "string", "property": [{"maxLength": "1"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Carer Status", "description": "The carer status is important to ensure provision is put in place to support the person receiving and providing care.
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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\u2019s gender reassignment with or\n without a gender reassignment certificate recognise that the definitions used do not reflect today\u2019s more inclusive society. We have provided feedback on this to NHS data dictionary team in NHS Digital who are actively addressing this area, and any updates to the NHS data dictionary will update our standards.
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* Personal contacts e.g., next of kin, in case of emergency contact, lasting power of attorney, dependents, informal carers etc.
\n* Health/care professional contacts e.g., social worker, hospital clinician, care coordinator, key worker, Independent Mental Capacity Advocate (IMCA) etc.
\nName, relationship, role (if formal role), contact details and availability, e.g. out of hours.
\n \n ", "valueSets": "Details of relevant contacts, such as carers or family members, as recorded on the local system, or volunteered by the person. This will be a free text list of relevant contacts.", "valueDomain": [{"type": "string"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Educational establishment", "description": "If the person is a child, name and address of where the child attends, eg play group, nursery, school.", "valueSets": "Free text or ODS code where available.", "valueDomain": [{"type": "text"}]}]}, {"type": "group", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "M", "name": "GP practice", "implamentationGuidance": "\nDetails of the person's GP practice.
\n ", "concept": [{"type": "group", "minimumMultiplicity": "1", "maximumMultiplicity": "*", "mro": "M", "name": "GP practice record entry", "description": "This is an GP practice record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items", "informationType": "Record", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "GP name", "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 Dempographics 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": "\nA description of how you communicate normally including any communication aids you use, for example a hearing aid.
\nDescribe how you would like others to engage and communicate with you, including how you would like to be addressed.
\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| \n \n \n \n \n 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 \n | \n
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A description of how and when you want someone caring for you to support you.
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A description of what is also worth knowing about you for people caring or supporting you.
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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": "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\n The record entry allows recording of multiple referrals\n
\n ", "description": "This is the referral details record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.", "informationType": "Event.Record", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date", "description": "The date of referral", "valueSets": "Date and time", "valueDomain": [{"type": "datetime", "property": [{"timeStampPrecision": "YMDHM"}]}]}, {"type": "group", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "M", "name": "Referrer details", "implamentationGuidance": "\n\n This should be completed by the system for the referrer\n
\n ", "description": "The details of the referrer that is making the referral or the transfer.\n There is currently no code for Social Prescribing, so this element does not need to be used\n
\n ", "description": "The specialty of the referrer.", "valueSets": "NHS data dictionary - Activity treatment function code \n ", "valueDomain": [{"type": "string", "property": [{"maxLength": "3"}]}]}, {"type": "group", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "M", "name": "Service", "description": "The service of the referrer.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implamentationGuidance": "\n\n There is currently no code for Social Prescribing, so this element does not need to be used\n
\n ", "description": "The coded value for service", "valueSets": "SNOMED CT: -\u00a01127531000000102 |Services simple reference set (foundation metadata concept)|"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "group", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "M", "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 \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": "1", "maximumMultiplicity": "1", "mro": "M", "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 \u00a0\n
\n \u2018Reason for referral\u2019 is used if needed to qualify those presenting complaints or issues and the appropriateness of referring to Social Prescribing .\n
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\n This section captures details of the contacts between the social prescribing link worker and the person\n
\n ", "description": "The details of the person\u2019s 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.", "informationType": "Event.Record", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date and time of contact", "description": "Date and time of the contact.", "valueSets": "Date and time.", "valueDomain": [{"type": "datetime", "property": [{"timeStampPrecision": "YMDHM"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Location of contact", "description": "The location where the contact took place.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for location", "valueSets": "NHS data dictionary : - Organisation data service code \n\n Details of the professional and their organisation should be filled in automatically from the login details\n
\n ", "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 : -\u00a0 ukcorepractitionerrolecode \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 values set : -\u00a0 ukcorepractitionerrolecode \n\n This is not mandatory for providing care but is deemed as a 'Must have' to support other activities.
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These are the person's complaints or issues as perceived by the referrer.\u00a0 There can be multiple complaints or issues. \n
There is a new refset \"Social prescribing needs and concerns simple reference set\" (https://termbrowser.nhs.uk/?perspective=full&conceptId1=1373501000000105&edition=uk-edition&release=&server=https://termbrowser.nhs.uk/sct-browser-api/snomed&langRefset=999001261000000100,999000691000001104) (SCTID: 1373501000000105) which should be used in place of the \"Health issues simple refset\" specified in the\n valueset.\u00a0
\n ", "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", "implamentationGuidance": "\nUse free text where a code is not available or to supplement coded information.
\n ", "valueSets": "Free text", "valueDomain": [{"type": "string", "property": [{"maxLength": "150"}]}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Person reported complaints or issues", "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.", "informationType": "Event.Record", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Problem list", "implamentationGuidance": "\n\n T\n his section allows for all relevant diagnoses, symptoms, conditions, problems and issues. However when referring for social prescribing, the problems\n here should be relevant to Social Prescribing referral.\n
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\n\n This would include disabilities, including learning disabilities, and conditions such as autism where they fall into the above categories i.e. are\n 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 or under the individual requirements section.\n
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\n\n The differential diagnoses should only be included in free text in the comments field, and not in a coded diagnosis field until confirmed with\n confidence. 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.\n \n
\n\n This section includes details of a person\u2019s assessments allowing for unstructured, semistructured and\n 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.) This section would also accommodate the results of any more structured assessment tools completed (e.g. screening tools/outcomes\n measures such as PHQ-9 or GAD-7). Numeric results of any assessments completed can also be included.\n \n
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\n \n This section includes details of a person\u2019s assessments allowing for unstructured, semi structured 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,\n Mental State Examination etc.)\n \n
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\n This section would also accommodate the results of any more structured assessment tools completed (e.g.\n ONS4 Personal Wellbeing Score or Warwick-Edinburgh Mental Wellbeing Scales (WEMWBS)\u00a0\n Numeric results of any assessments completed can also be included.\n \n
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\nSNOMED CT: - <281694009 |Finding of at risk (finding)|
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\nThis section replicates the section in the Personalised Care and Support Plan.\u00a0 Where a link worker who has read and write access to a person\u2019s single shared care & support plan. The Link Worker can use the shared care & support plan for their social prescribing activities.\u00a0 Otherwise this section should be included\n into the social prescribing system.\u00a0
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Detailed guidance for using a Personalised Care and Support Plan is available here: https://theprsb.org/standards/personalisedcareandsupportplan/\u00a0
There is a new refset \"Social prescribing needs and concerns simple reference set\" (https://termbrowser.nhs.uk/?perspective=full&conceptId1=1373501000000105&edition=uk-edition&release=&server=https://termbrowser.nhs.uk/sct-browser-api/snomed&langRefset=999001261000000100,999000691000001104) (SCTID: 1373501000000105) which should be used in place of the \"Health issues simple refset\" specified in the\n valueset.\u00a0
\n ", "description": "The coded value associated with the person's needs, concerns or problems.", "valueSets": "\n| \n \n \n 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\n importance or priority to the person. \n | \n
There is a new refset \"Social prescribing support simple reference set\" (https://termbrowser.nhs.uk/?perspective=full&conceptId1=1373511000000107&edition=uk-edition&release=&server=https://termbrowser.nhs.uk/sct-browser-api/snomed&langRefset=999001261000000100,999000691000001104) (SCTID: 1373511000000107) which should be used in place of the \"Health issues simple refset\" specified in the\n valueset.\u00a0
\n ", "description": "The coded value for the action.| \n \n \n \n \n \n | \n