Digital Maternity Record Standard Release 2
V0.1 Initial publication.
V0.2 Updates during endorsement period.
V0.3 Updated following feedback during ISN process.
V0.4 Updates during endorsement period to align with Maternity Secondary Use Dataset.
V0.5 Update to smoking record and inclusion of Document section
", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person demographics", "implementationGuidance": "This section contains the person\u2019s demographic and contact details including key identifiers (e.g. name, date of birth, NHS number, address etc.) Personal Demographic Service (PDS) will be used as the source of information to ensure the elements within this section can be fulfilled. The information under this heading will be populated from\n the PDS. NHS Spine compliant systems are needed to obtain traced NHS Numbers. Where an organisation does not have a system linked to the PDS, other demographic fields will need to be used, with local person identity matching software. A history of Local Patient Identifiers should be kept so it is important to understand the organisation which assigned the Local\n Patient Identifier.
", "description": "The person's details and contact information.", "informationType": "Record", "concept": [{"type": "group", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "M", "name": "Person name", "implementationGuidance": "Details of the person's name.", "description": "Details of the person's name.
", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person first name", "implementationGuidance": "The first name(s) of the person. This includes middle names.", "description": "The first name(s) of the person. This includes middle names.", "valueSets": "NHS data dictionary : - Person given name
", "valueDomain": [{"type": "string", "property": [{"maxLength": "35"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person family name", "implementationGuidance": "The family name or surname of the person.", "description": "The family name or surname of the person.
", "valueSets": "NHS data dictionary : - Person family name \nNHS data dictionary : - Person full name
", "valueDomain": [{"type": "string", "property": [{"maxLength": "70"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Title", "implementationGuidance": "Person's title.", "description": "Person's title.
", "valueSets": "NHS data dictionary : - Patient title
", "valueDomain": [{"type": "string", "property": [{"maxLength": "35"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person name suffix", "implementationGuidance": "A textual suffix that may be added to the end of a person's name, for example, OBE, MBE, BSc, JP, GM, etc.", "description": "A textual suffix that may be added to the end of a person's name, for example, OBE, MBE, BSc, JP, GM, etc.
", "valueSets": "NHS data dictionary : - Person name suffix
", "valueDomain": [{"type": "string", "property": [{"maxLength": "35"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person full name", "implementationGuidance": "The full name of the person in text representation.", "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": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date of birth", "implementationGuidance": "The date of birth of the person.", "description": "The date of birth of the person.", "valueSets": "NHS data dictionary : - Person birth date
", "valueDomain": [{"type": "date", "property": [{"timeStampPrecision": "YMD!"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "NHS number", "implementationGuidance": "NHS Number should have the option to record \u2018not known\u2019 or \u2018not available\u2019. Existing national guidance SHOULD be followed, including how to handle patients without an NHS Number, e.g. overseas visitors.
", "description": "The unique identifier for a person within the NHS in England and Wales.", "valueSets": "NHS data dictionary : - NHS number
", "valueDomain": [{"type": "string", "property": [{"maxLength": "10"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "NHS number status indicator", "implementationGuidance": "Provides an indication of the reliability of an NHS Number.", "description": "Provides an indication of the reliability of an NHS Number.", "valueDomain": [{"type": "string", "property": [{"maxLength": "2"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Other NHS identifier group ", "implementationGuidance": "NHS identifier other than NHS number.", "description": "NHS identifier other than NHS number.
", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Other NHS identifier", "implementationGuidance": "Details of the other NHS identifier required to be held against the person's record.", "description": "Details of the other NHS identifier required to be held against the person's record.
", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for other NHS identifier.", "description": "The coded value for other NHS identifier.
", "valueDomain": [{"type": "string"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text", "description": "Free text
", "valueDomain": [{"type": "text"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Type of other NHS identifier", "implementationGuidance": "Details that describe the type of NHS identifier being used. Country specific or local identifier, e.g. Community Health Index (CHI) in Scotland.", "description": "Details that describe the type of NHS identifier being used. Country specific or local identifier, e.g. Community Health Index (CHI) in Scotland.
", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for the type of other NHS identifier e.g., CHI code.", "description": "The coded value for the type of other NHS identifier e.g., CHI code.
"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text", "description": "Free text", "valueDomain": [{"type": "string"}]}]}]}, {"type": "group", "minimumMultiplicity": "1", "maximumMultiplicity": "*", "mro": "M", "name": "Person's address", "implementationGuidance": "Person\u2019s usual place of residence, and where relevant temporary and correspondence addresses.", "description": "Person\u2019s usual place of residence, and where relevant temporary and correspondence addresses.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Address line 1", "implementationGuidance": "Person's first line of address.", "description": "Person's first line of address.", "valueSets": "NHS data dictionary : -\u00a0 Address line 1
NHS data dictionary : - Address line 2
NHS data dictionary : - Address line 3
", "valueDomain": [{"type": "string", "property": [{"maxLength": "35"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Address line 4", "implementationGuidance": "Person's fourth line of address.", "description": "Person's fourth line of address.", "valueSets": "NHS data dictionary : - Address line 4
NHS data dictionary : - Address line 5
Unique Property Reference Number (UPRN) is the unique identifier for every addressable location across the UK. It consists of\u00a0numbers of up to 12 digits in length.
\n ", "valueSets": "UPRN string
https://www.geoplace.co.uk/addresses-streets/location-data/the-uprn.
", "valueDomain": [{"type": "string"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person's contact details", "implementationGuidance": "Details of the person's contact information.", "description": "Details of the person's contact information.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Preferred contact method", "implementationGuidance": "Preferred contact method, e.g. email, letter, phone, text message etc.", "description": "Preferred contact method, e.g. email, letter, phone, text message etc.", "valueSets": "NHS data dictionary : - Communication contact method
", "valueDomain": [{"type": "string", "property": [{"maxLength": "1"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Person's telephone number details", "implementationGuidance": "The person's telephone number details.", "description": "The person's telephone number details.
", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person's telephone number", "implementationGuidance": "The person's 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": "Person's telephone number type", "implementationGuidance": "The contact type e.g. home, mobile.", "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", "implementationGuidance": "The preferred order of use for the telephone number.", "description": "The preferred order of use for the telephone number.
", "valueSets": "Preference of use 1-5, 1 being the highest."}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Person's email address details", "implementationGuidance": "Details of the person's email address.", "description": "Details of the person's email address.
", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person's email address", "implementationGuidance": "Email address of the person.", "description": "Email address of the person.", "valueSets": "NHS data dictionary : - Contact email address (patient or lead contact)
", "valueDomain": [{"type": "string", "property": [{"maxLength": "255"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person's email address type", "implementationGuidance": "The type of email address, home, work.", "description": "\nThe 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", "implementationGuidance": "Contact details via fax, sms, url.", "description": "\nThe person's preferred pronoun e.g. she/he/they.
", "valueSets": "Free Text", "valueDomain": [{"type": "string"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Gender", "implementationGuidance": "The definitions used for phenotypic sex and gender use the NHS data dictionary definitions to ensure interoperability with other systems. However, we recognise that the definitions used do not reflect today\u2019s more inclusive society. We have provided feedback on this to NHS data dictionary team who are actively addressing this area, and any\n updates to the NHS data dictionary will update our standards. Phenotypic sex and gender data items may cause accidental disclosure of gender reassignment without consent. This is because both fields are included in the demographic model. Having both may show a difference and therefore disclose gender reassignment without consent. It is unlawful to disclose,\n without consent, a person\u2019s gender reassignment with or without a gender reassignment certificate Section 22 of the Gender 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\n involved in direct medical care, but not currently for administrative and non-medical staff. For the full Act, see https://www.legislation.gov.uk/ukpga/2004/7/contents. This risk can be mitigated by appropriate implementation in a shared care record; refer to\n the clinical safety case report and hazard log. One option is to leave out the \u201cPhenotypic Sex\u201d field but the implications and potential risks of that will need to be considered. The alternative is to ensure the design of the Shared Care Record, including its Information Governance model, reduces this risk to an acceptable level as described in the clinical\n safety case and hazard log. A further mitigation on implementation could be to record self-expressed gender in the administrative area of systems, and record sex at birth in a separate clinical area, that can only be accessed by medical staff.
", "description": "The person's stated gender.", "valueSets": "NHS data dictionary : - Person stated gender code
Once approved by the Data Alliance Partnership Board, the Ethnic Category 2021 reference set should be used for this element. Find a link to the placeholder webpage here: https://www.datadictionary.nhs.uk/attributes/ethnic_category_2021.html
", "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": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Phenotypic sex", "implementationGuidance": "The definitions used for phenotypic sex and gender use the NHS data dictionary definitions to ensure interoperability with other systems. However, we recognise that the definitions used do not reflect today\u2019s more inclusive society. We have provided feedback on this to NHS data dictionary team who are actively addressing this area, and any\n updates to the NHS data dictionary will update our standards. Phenotypic sex and gender data items may cause accidental disclosure of gender reassignment without consent. This is because both fields are included in the demographic model. Having both may show a difference and therefore disclose gender reassignment without consent. It is unlawful to disclose,\n without consent, a person\u2019s gender reassignment with or without a gender reassignment certificate Section 22 of the Gender 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\n involved in direct medical care, but not currently for administrative and non-medical staff. For the full Act, see https://www.legislation.gov.uk/ukpga/2004/7/contents. This risk can be mitigated by appropriate implementation in a shared care record; refer to\n the clinical safety case report and hazard log. One option is to leave out the \u201cPhenotypic Sex\u201d field but the implications and potential risks of that will need to be considered. The alternative is to ensure the design of the Shared Care Record, including its Information Governance model, reduces this risk to an acceptable level as described in the clinical\n safety case and hazard log. A further mitigation on implementation could be to record self-expressed gender in the administrative area of systems, and record sex at birth in a separate clinical area, that can only be accessed by medical staff.
", "description": "The phenotypic sex of the individual. This is the observed sex of a person at birth.
", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for phenotypic sex.", "description": "The coded value for phenotypic sex.
", "valueSets": "NHS Data dictionary : - Person phenotypic sex
"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text field to be used if no code is available.", "description": "Free text field to be used if no code is available.
", "valueDomain": [{"type": "text"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Photograph", "implementationGuidance": "A photograph of the person for identification and to show what the person looks like normally.", "description": "A photograph of the person for identification and to show what the person looks like normally.", "valueSets": "\nMultimedia file
\n ", "valueDomain": [{"type": "blob"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Country of birth code", "implementationGuidance": "The country of birth of the person.", "description": "The country of birth of the person.", "valueSets": "NHS data dictionary :- Country code (birth) \n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Marital status", "implementationGuidance": "An indicator to identify the legal marital status of the person.", "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": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Armed forces indicator", "implementationGuidance": "An indication of whether the person is a member of the armed forces or is a dependent of a person who is a member of the armed forces.", "description": "An indication of whether the person is a member of the armed forces or is a dependent of a person who is a member of the armed forces.
", "valueSets": "NHS Data Dictionary (TBC)
"}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Immigration details", "implementationGuidance": "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.", "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", "implementationGuidance": "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.
", "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", "implementationGuidance": "Start date of immigration status", "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", "implementationGuidance": "End date of immigration status", "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", "implementationGuidance": "Relevant comments about the person's immigration status", "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": "Date of death", "implementationGuidance": "The date of death of the person.", "description": "The date of death of the person.", "valueSets": "NHS data dictionary :- Person death date \n ", "valueDomain": [{"type": "date", "property": [{"timeStampPrecision": "YMD!", "default": "10"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "GP practice", "implementationGuidance": "\nThis section contains details of the GP practice where the woman / birthing person is registered. This information would be sourced from PDS. This will include the GP practice identifier code.
\n\u2018GP practice identifier\u2019 does not need to be a displayed field. It is intended to be used to provide the GP practice details via lookup from national registers.
\nMany people will not offer a named GP. Only the \u2018GP practice details\u2019 section would need to be completed in these situations
\nA woman / birthing person may be registered with more than one GP practice. Normally people are registered with one practice, but may be treated as a temporary registration (e.g. serving personnel who have both civilian and military GPs) by another practice. The registered GP practice can be obtained from the PDS. Suppliers should enable more than one GP\n practice to be recorded to accommodate temporary registration. Communications will go to the GP surgery that the patient is permanently registered with. However, sometimes a GP who is serving a patient on a temporary basis may also need to access the transfer of care communication. In this instance, both GP practices should be recorded.
\nIf a woman / birthing person is not registered with a GP practice, then the GP practice record entry should appear in the Digital Maternity Record Standard with the text \"No known GP practice\".
\nA woman / birthing person may choose to opt out of registering with a GP practice. System design
\nshould enable this to be recorded to accommodate this personal requirement to refrain from GP registration.
\nDetails of the person's GP practice.
\n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "GP practice record entry", "implementationGuidance": "This is a 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.", "description": "This is a 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", "implementationGuidance": "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.", "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", "implementationGuidance": "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.", "description": "\nName 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.
\n ", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "GP practice identifier", "implementationGuidance": "The identifier of the registered GP practice.", "description": "The identifier of the registered GP practice.", "valueSets": "\nThis section allows for the recording of all instances where a woman / birthing person is admitted to a healthcare setting during the maternity episode and should include the relevant site Organisation Data Service (ODS) code where applicable.
\n ", "description": "Admission details", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Admission details record entry", "implementationGuidance": "This is the admission details record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.", "description": "This is the admission details record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.", "informationType": "Event.Record", "concept": [{"type": "item", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "M", "name": "Date of admission", "implementationGuidance": "Date and time the person was admitted to hospital.", "description": "Date and time the person was admitted to hospital.", "valueSets": "Date and time", "valueDomain": [{"type": "datetime", "property": [{"timeStampPrecision": "YMDHM"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Admitted to", "implementationGuidance": "The hospital the person was admitted to.", "description": "The hospital the person was admitted to.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for admission to", "description": "The coded value for admission to", "valueSets": "NHS data dictionary : - Organisations code of provider \n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text field to be used if no code is available", "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": "Specialty", "implementationGuidance": "The specialty e.g. physiotherapy, oncology, mental health etc", "description": "The specialty e.g. physiotherapy, oncology, mental health etc", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for specialty", "description": "The coded value for specialty", "valueSets": "NHS data dictionary :- Activity treatment function code \n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text field to be used if no code is available", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Responsible care professional", "implementationGuidance": "The care professional who has overall responsibility for the person (may not actually see the person)", "description": "The care professional who has overall responsibility for the person (may not actually see the person)", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "implementationGuidance": "The name of the responsible care professional.", "description": "The name of the responsible care professional.", "valueSets": "Free text.", "valueDomain": [{"type": "string", "property": [{"maxLength": "70"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "implementationGuidance": "The role of the responsible consultant.", "description": "The role of the responsible consultant.", "valueSets": "\nAlignment to the workforce dataset NHS Occupation codes primarily is advised. Where no code is available, free text may be used.
\nNational Workforce Data Set (NWD) NHS Occupation codes are found here: -\u00a0https://digital.nhs.uk/data-and-information/data-collections-and-data-sets/data-sets/national-workforce-data-set-nwd-and-nhs-occupation-codes. To access the list of roles, download the 'NWD dataset specification' using the link on the page.
\nThe Staff Groups and Job Roles are listed in the \u2018NWD Class & Codes Appendix\u2019 tab of the attached NWD Dataset from row 640. The 'Staff Group' and 'Job Role' segments are contained in one field named 'Job' which work together e.g. Staff Group = Nursing & Midwifery Registered and Job Role = Staff Nurse.
\n "}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Reason for admission", "implementationGuidance": "The health problems and issues experienced by the person that prompted the decision to admit to hospital e.g. chest pain, mental health crisis, blackout, fall, a specific procedure, intervention, investigation or treatment, non compliance with treatment.", "description": "The health problems and issues experienced by the person that prompted the decision to admit to hospital e.g. chest pain, mental health crisis, blackout, fall, a specific procedure, intervention, investigation or treatment, non compliance with treatment.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for reason for admission", "description": "The coded value for reason for admission", "valueSets": "\n \n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text field to be used if no code is available", "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": "Readmission indicator", "implementationGuidance": "Indicator to show whether or not the admission is determined to be a readmission", "description": "\nIndicator to show whether or not the admission is determined to be a readmission
\n ", "valueSets": "1- Not readmitted
2- Readmitted
", "valueDomain": [{"type": "boolean"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Admission method", "implementationGuidance": "How the person was admitted to hospital e.g. elective, emergency, maternity, transfer etc.", "description": "How the person was admitted to hospital e.g. elective, emergency, maternity, transfer etc.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for admission method", "description": "The coded value for admission method", "valueSets": "NHS data dictionary:- Admission Method \n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text field to be used if no code is available", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Legal status on admission", "implementationGuidance": "Whether the person was admitted as informal or formal/detained.", "description": "Whether the person was admitted as informal or formal/detained.", "valueSets": "\nThis is the physical location of the patient. For inpatient, e.g., hospital ward, bed, theatre. For ambulatory care, e.g., health center, clinic, resources center, patient\u2019s home.
", "valueSets": "Free text", "valueDomain": [{"type": "string", "property": [{"maxLength": "150"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Individual accompanying person", "implementationGuidance": "Details of the accompanying individual and the extent to which they have provided the information about the person.", "description": "Details of the accompanying individual and the extent to which they have provided the information about the person.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "implementationGuidance": "Name of individual accompanying person.", "description": "Name of individual accompanying person.", "valueSets": "Free text", "valueDomain": [{"type": "string", "property": [{"maxLength": "70"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "implementationGuidance": "The role that the individual accompanying the person is fulfilling", "description": "\nThe role that the individual accompanying the person is fulfilling
\n "}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Relationship", "implementationGuidance": "Relationship of individual accompanying the person.", "description": "Relationship of individual accompanying the person.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for relationship to person.", "description": "The coded value for relationship to person.", "valueSets": "FHIR value set: - Person relationship type
"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text field to be used if no code is available", "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", "implementationGuidance": "Information about the extent to which the accompanying individual provided information about the person.", "description": "Information about the extent to which the accompanying individual provided information about the person.", "valueSets": "Free text.", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Alcohol record", "implementationGuidance": "\nCurrent alcohol consumption, alcohol consumption prior to pregnancy and alcohol consumption during the first few weeks of pregnancy should all be recorded. Where frequency of alcohol consumption and frequency of binge drinking are greater than one a week the actual number of days should be recorded.
\n ", "description": "Details of a person's alcohol record", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Audit questionnaire", "implementationGuidance": "Alcohol use disorder identification test (AUDIT) questionnaire", "description": "Alcohol use disorder identification test (AUDIT) questionnaire", "valueSets": "\nSNOMED-CT coded.
\nPlease note the codes in this section are still under review by NHS Digital and may change (24-05-2018). Any changes will be reflected (and highlighted) in GMS contract changes 2018/19 guidance and audit requirements (NHS Employers). www.nhsemployers.org/gms201819
\nAssessment using Alcohol Use Disorders Identification Test Consumption [SNOMED-CT::1084571000000109]
\nAlcohol use disorder identification test consumption questionnaire [SNOMED-CT::335811000000106]
\nAlcohol consumption screening test declined [SNOMED-CT::428073005]
\nAlcohol assessment declined [SNOMED-CT::361731000000101]
\n ", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date", "implementationGuidance": "Date of person's AUDIT questionnaire.", "description": "\nDate of person's AUDIT questionnaire.
\n ", "valueSets": "Date and time", "valueDomain": [{"type": "datetime", "property": [{"timeStampPrecision": "YMD"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "AUDIT-C cluster", "implementationGuidance": "AUDIT-C* questions: Frequency of consumption, Typical consumption, Binge drinking.*", "description": "\n0: Never [No drinking of alcohol in the past year.]
\n1: Monthly or Less [Drinking alcohol monthly or less frequently during the past year.]
\n2: 2 to 4 Times a Month [Drinking alcohol two to four times a month during the past year.]
\n3: 2 to 3 Times a Week [Drinking alcohol two to three times a week during the past year.]
\n4: 4 or More Times a Week [Drinking alcohol four or more times a week during the past year.]
\n "}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Typical consumption cluster", "implementationGuidance": "Details of the person's typical consumption", "description": "Details of the person's typical consumption", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Absolute value", "implementationGuidance": "How many drinks did you have on a typical day when you were drinking in the past year?", "description": "\nHow many drinks did you have on a typical day when you were drinking in the past year?
\n ", "valueSets": "\nInteger (0 to n)
\n ", "valueDomain": [{"type": "count"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Categorical value", "implementationGuidance": "How many drinks did you have on a typical day when you were drinking in the past year? This item is generated from Typical consumption (absolute value).", "description": "\nHow many drinks did you have on a typical day when you were drinking in the past year? This item is generated from Typical consumption (absolute value).
\n ", "valueSets": "\n0: 0 to 2 [Zero to two drinks of alcohol on a typical day in the past year.]
\n1: 3 or 4 [Three or four drinks of alcohol on a typical day in the past year.]
\n2: 5 or 6 [Five or six drinks of alcohol on a typical day in the past year.]
\n3: 7 to 9 [Seven, eight or nine drinks of alcohol on a typical day in the past year.]
\n4: 10 or More [Ten or more drinks of alcohol on a typical day in the past year.]
\n "}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Binge drinking", "implementationGuidance": "How often did you have six or more drinks on one occasion in the past year?", "description": "\nHow often did you have six or more drinks on one occasion in the past year?
\n ", "valueSets": "\n0:Never [Never, in the past year.]
\n1: Less than Monthly [Less than monthly, during the past year.]
\n2: Monthly [Monthly, during the past year.]
\n3: Weekly [Weekly, during the past year.]
\n4: Daily or Almost Daily [Daily, or almost daily, during the past year.]
\n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "AUDIT-C total score", "implementationGuidance": "AUDIT-C *total score calculated from the 3 questions only: Frequency of consumption, Typical consumption (categorical value), Binge drinking.*", "description": "AUDIT-C total score calculated from the 3 questions only: Frequency of consumption, Typical consumption (categorical value), Binge drinking. \n ", "valueSets": "\nSNOMED-CT coded with associated value calculated from the first 3 questions only.
\n \nPlease note the codes in this section are still under review by NHS Digital and may change (24-05-2018). Any changes will be reflected (and highlighted) in GMS contract changes 2018/19 guidance and audit requirements (NHS Employers). www.nhsemployers.org/gms201819
\n \n[SNOMED-CT::1084581000000106] (Alcohol Use Disorders Identification Test - Consumption score)
\n \nAnd add a value to a field associated with the code to record the score. The score are as follows:
\nCurrent non-drinker (AUDIT-C score = 0)
\nLow risk of alcohol misuse (AUDIT-C score 1-4)
\n \nHigh risk of alcohol misuse (AUDIT-C score >=5)
\n ", "valueDomain": [{"type": "count"}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "if AUDIT-C score >=5", "implementationGuidance": "Populate this section if the AUDIT-C score is >=5.", "description": "Populate this section if the AUDIT-C score is >=5.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Inability to stop", "implementationGuidance": "How often during the last year have you found that you were not able to stop drinking once you had started?", "description": "\nHow often during the last year have you found that you were not able to stop drinking once you had started?
\n ", "valueSets": "\n0: Never [Never, in the past year.]
\n1: Less than Monthly [Less than monthly, during the past year.]
\n2: Monthly [Monthly, during the past year.]
\n3: Weekly [Weekly, during the past year.]
\n4: Daily or Almost Daily [Daily, or almost daily, during the past year.]
\n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Failed expectations", "implementationGuidance": "How often during the last year have you failed to do what was normally expected of you because of drinking?", "description": "\nHow often during the last year have you failed to do what was normally expected of you because of drinking?
\n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Morning drinking", "implementationGuidance": "How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?", "description": "\nHow often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?
\n ", "valueSets": "\n \n0: Never [Never, in the past year.]
\n1: Less than Monthly [Less than monthly, during the past year.]
\n2: Monthly [Monthly, during the past year.]
\n3: Weekly [Weekly, during the past year.]
\n4: Daily or Almost Daily [Daily, or almost daily, during the past year.]
\n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Guilt/remorse", "implementationGuidance": "How often during the last year have you had a feeling of guilt or remorse after drinking?", "description": "\nHow often during the last year have you had a feeling of guilt or remorse after drinking?
\n ", "valueSets": "\n0: Never [Never, in the past year.]
\n1: Less than Monthly [Less than monthly, during the past year.]
\n2: Monthly [Monthly, during the past year.]
\n3: Weekly [Weekly, during the past year.]
\n4: Daily or Almost Daily [Daily, or almost daily, during the past year.]
\n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Loss of memory", "implementationGuidance": "How often during the last year have you been unable to remember what happened the night before because of your drinking?", "description": "\nHow often during the last year have you been unable to remember what happened the night before because of your drinking?
\n ", "valueSets": "\n0: Never [Never, in the past year.]
\n1: Less than Monthly [Less than monthly, during the past year.]
\n2: Monthly [Monthly, during the past year.]
\n3: Weekly [Weekly, during the past year.]
\n4: Daily or Almost Daily [Daily, or almost daily, during the past year.]
\n ", "valueDomain": [{"type": "count"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Injuries", "implementationGuidance": "Have you or someone else been injured because of your drinking?", "description": "\n \nHave you or someone else been injured because of your drinking?
\n ", "valueSets": "\n0: No [No occurrence.]
\n2: Yes, but not in the last year. [Yes, this has occurred, but not in the last year.]
\n4: Yes, during the last year. [Yes this has occurred during the last year.]
\n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "External concern", "implementationGuidance": "Has a relative, friend, doctor, or other health care worker been concerned about your drinking or suggested you cut down?", "description": "\nHas a relative, friend, doctor, or other health care worker been concerned about your drinking or suggested you cut down?
\n ", "valueSets": "\n\n
\n
AUDIT total score calculated from the 10 AUDIT questions.
\n ", "valueSets": "\n \n \nSNOMED-CT coded with associated value calculated from the 10 AUDIT questions.
\nPlease note the codes in this section are still under review by NHS Digital and may change (24-05-2018). Any changes will be reflected (and highlighted) in GMS contract changes 2018/19 guidance and audit requirements (NHS Employers). www.nhsemployers.org/gms201819
\nAlcohol use disorders identification test score [SNOMED-CT::443280005]
\n
And add a value to a field associated with the code to record the score. The score are as follows:
\u2022 0\u20137 indicates sensible or lower risk drinking
\n\u2022 8\u201315 indicates increasing risk drinking
\n\u2022 16\u201319 indicates higher risk drinking
\n\u2022 20 and over indicates possible alcohol dependence
\n "}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Number of alcohol units consumed per week", "implementationGuidance": "The number of alcohol units consumed by the patient per week.", "description": "\n \nThe number of alcohol units consumed by the patient per week.
\n
Integer (0 to n)
\n ", "valueDomain": [{"type": "count"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "History of heavy alcohol use", "implementationGuidance": "Whether the patient reports a history of heavy alcohol use in the past.", "description": "\nWhether the patient reports a history of heavy alcohol use in the past.
\n ", "valueSets": "\nHistory of heavy alcohol use
\nNo history of heavy alcohol use
\nNot known
\n ", "valueDomain": [{"type": "string"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Comment", "implementationGuidance": "Additional information about alcohol use or its management not captured in other fields.", "description": "Additional information about alcohol use or its management not captured in other fields.", "valueSets": "Free text", "valueDomain": [{"type": "text"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Personal contacts", "implementationGuidance": "\nThis heading allows for the recording of a list of personal contacts (e.g. family, friends, relatives etc.)
\nComments should be used to share information such as if a particular contact should be called in an emergency etc.
\nWhere a known donor is present, the system should prioritise the contact information of the individuals listed under the personal contacts section, rather than the individuals within the family history section.
\nThe relationship the personal contact has to the person, e.g. father, grandmother, family friend etc. Includes additional roles the person performs on behalf of the other (e.g. carer, next of kin, emergency contact, dependent, etc.).
\n ", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for relationship.", "description": "\nThe coded value for relationship.
\n ", "valueSets": "FHIR value set: Person relationship type
"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text field to be used if no code is available.", "description": "\nFree text field to be used if no code is available.
\n ", "valueSets": "\nThe personal care responsibilities undertaken for the person by the contact.
", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for personal care responsibilities.", "description": "\nThe coded value for personal care responsibilities.
\n ", "valueSets": "SNOMED CT
< 304492001 | Activities of daily living assessment (procedure) |
"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text field to be used if no code is available.", "description": "\nFree text field to be used if no code is available.
\n ", "valueDomain": [{"type": "string"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "implementationGuidance": "Contact details of the personal contact (e.g. telephone number, address, email address etc.)", "description": "Contact details of the personal contact (e.g. telephone number, address, email address etc.)", "valueSets": "Free Text", "valueDomain": [{"type": "string", "property": [{"maxLength": "70"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Comments", "implementationGuidance": "Notes on the significance of the personal contact to the person.", "description": "Notes on the significance of the personal contact to the person.", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Discharge details", "implementationGuidance": "\nThis section includes the summary details of the person\u2019s discharge, but not the actual discharge content which is shared in the relevant sections such as problem list or procedures. This should include all instances of discharge from a healthcare setting with relevant ODS codes and readable names of the discharging wards or departments of organisations\n where available.
\nThe information recorded here is complementary to the discharge summary. Any transfer of care or movement between services can be recorded using existing PRSB transfer of care headings (i.e. discharge summary, EC discharge summary etc).
\n \nA group containing the coded value or free text entry of Discharge Location
\n ", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded Value", "implementationGuidance": "Coded Value for discharge location", "description": "\nCoded Value for discharge location
\n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text entry to be used when coded value is not available", "description": "\nFree text entry to be used when coded value is not available
\n ", "valueDomain": [{"type": "string"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Discharging consultant", "implementationGuidance": "\nThe consultant responsible for the person at time of discharge.
\n ", "description": "The consultant responsible for the person at time of discharge.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "implementationGuidance": "\nThe name of the discharging consultant.
\n ", "description": "The name of the discharging consultant", "valueSets": "Free text", "valueDomain": [{"type": "string", "property": [{"maxLength": "70"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "implementationGuidance": "\nThe role of the discharging consultant.
\n ", "description": "The role of the discharging consultant", "valueSets": "\nAlignment to the workforce dataset NHS Occupation codes primarily is advised. Where no code is available, free text may be used.
\nNational Workforce Data Set (NWD) NHS Occupation codes are found here: -\u00a0https://digital.nhs.uk/data-and-information/data-collections-and-data-sets/data-sets/national-workforce-data-set-nwd-and-nhs-occupation-codes. To access the list of roles, download the 'NWD dataset specification' using the link on the page.
\nThe Staff Groups and Job Roles are listed in the \u2018NWD Class & Codes Appendix\u2019 tab of the attached NWD Dataset from row 640. The 'Staff Group' and 'Job Role' segments are contained in one field named 'Job' which work together e.g. Staff Group = Nursing & Midwifery Registered and Job Role = Staff Nurse.
\n \n "}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Discharge method", "implementationGuidance": "\nThe method of discharge from hospital e.g. person discharged on clinical advice or with clinical consent; person discharged him/herself or was discharged by a relative or advocate.
\n ", "description": "The method of discharge from hospital e.g. person discharged on clinical advice or with clinical consent; person discharged him/herself or was discharged by a relative or advocate.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for discharge method", "description": "The coded value for discharge method", "valueSets": "NHS data dictionary : - Discharge method \n ", "valueDomain": [{"type": "string", "property": [{"maxLength": "1"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text field to be used if no code is available", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Discharging specialty", "implementationGuidance": "\nThe specialty of the consultant responsible for the person at the time of discharge.
\n ", "description": "The specialty of the consultant responsible for the person at the time of discharge.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for discharging speciality", "description": "\nThe department from which the person is discharged.
\n ", "description": "The department from which the person is discharged.", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Legal status on discharge", "implementationGuidance": "\nWhether the person was discharged as informal or formal/ detained.
\n ", "description": "Whether the person was discharged as informal or formal/detained.", "valueSets": "NHS data dictioanary : - Legal status on discharge \n ", "valueDomain": [{"type": "string", "property": [{"maxLength": "2"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Discharge destination ", "implementationGuidance": "Discharge destination details.", "description": "\nThe destination of the person on discharge from hospital e.g. usual place of residence, NHS run care home.
\n ", "description": "The destination type of the person on discharge from hospital e.g. usual place of residence, NHS run care home.
", "valueSets": "NHS data dictionary :- Discharge Destination \n ", "valueDomain": [{"type": "string", "property": [{"maxLength": "2"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Discharge address", "implementationGuidance": "\nAddress to which the person is discharged if not the usual place of residence.
\n ", "description": "Address to which the person is discharged if not the usual place of residence.", "valueSets": "NHS data dictionary :- Address \n ", "valueDomain": [{"type": "string", "property": [{"minLength": "35", "maxLength": "175"}]}]}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Clinical risk factors", "implementationGuidance": "This is where clinical risk factors that have been shown to be associated with the development of a medical condition being considered as a diagnosis/differential diagnosis are recorded. These risk factors may not be an issue in isolation, but may increase the risk of other issues arising.
Factors that have been shown to be associated with the development of a medical condition being considered as a diagnosis/differential diagnosis. E.g. being overweight, smoker, no use of sun screen, enzyme deficiency.
", "valueSets": "Free text", "valueDomain": [{"type": "text"}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Assessments", "implementationGuidance": "Details of the person's assessments", "description": "Details of the person's assessments"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Clinical risk assessment", "implementationGuidance": "Specific risk assessments required/undertaken.", "description": "Specific risk assessments required/undertaken.", "valueSets": "Coded (SNOMED CT) or text"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Risk mitigation", "implementationGuidance": "Action taken to reduce the clinical risk and date actions.", "description": "Action taken to reduce the clinical risk and date actions.", "valueSets": "Free text", "valueDomain": [{"type": "text"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Patient at high risk", "implementationGuidance": "This patient is at high risk of clinical deterioration and will need an immediate response if called", "description": "This patient is at high risk of clinical deterioration and will need an immediate response if called", "valueDomain": [{"type": "string"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Allergies and adverse reactions", "implementationGuidance": "\nA record should be provided of allergic and adverse reactions relevant to the woman / birthing person. Coded information on causative agents is important to healthcare professionals to enable safe prescribing of medications.
\nIf relevant investigations and observations have been carried out and no allergies or adverse reactions identified then this section should appear with the text \u201cNo known allergies or adverse reactions\u201d. If no information is available about allergies or adverse reactions (but allergies or adverse reactions may have been identified), then this section\n should appear with the text \u201cInformation not available\u201d.
\nWhen a woman/ birthing person is diagnosed with an allergy related condition (e.g. anaphylactic shock or urticarial skin rash) this will also be entered in addition into the \u2018Condition\u2019 'Problem' element in the \u2018Problem List\u2019 heading section in the healthcare system.
\nGuidance on good practice recording of allergies and adverse reactions is provided by the National Institute of Health and Care Excellence (NICE): https://www.nice.org.uk/guidance/cg183/chapter/Recommendations
\nWhere there is a diagnostic code for an allergy recorded in the system, the system should trigger an allergy entry. There is a significant risk to patient safety if allergies are not explicitly and prominently displayed. Adverse reactions need to be treated in a similar manner.
\nInformation about probability of recurrence may be included in the allergy comments element if this has been identified.
\nCoded value for the type of reaction
\n ", "valueSets": "FHIR value set: Allergy intolerance
"}, {"type": "group", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "M", "name": "Causative agent", "implementationGuidance": "The agent such as food, drug or substances that has caused or may cause an allergy, intolerance or adverse reaction in this person Or \u201cNo known drug allergies or adverse reactions\u201d Or \u201cInformation not available\u201d", "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 \u201cNo known drug allergies or adverse reactions\u201d Or \u201cInformation not available\u201d", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for causative agent", "description": "The coded value for causative agent", "valueSets": "FHIR value set: UK Core allergy code
dm+d:- any code from the VTM, VMP, AMP, VMPP, AMPP and ingredient concept classes
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", "implementationGuidance": "Free text field to be used if no code is available", "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", "implementationGuidance": "Details of the reaction.", "description": "Details of the reaction.", "informationType": "Event.Record", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Substance", "implementationGuidance": "The substance, or a class of substances, that is considered to be responsible for the adverse reaction.", "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", "implementationGuidance": "The coded value for substance", "description": "The coded value for substance", "valueSets": "\nRefer to the UK Core Allergy Substance
\nA set of codes from the following dm+d (dictionary of medicines and devices) concept classes that define a medication or medication ingredient that the patient has an allergy or intolerance to:
\nVTM \u2013 Virtual Therapeutic Moiety
\nVMP \u2013 Virtual Medicinal Product
\nAMP \u2013 Actual Medicinal Product
\nIngredient
\nA set of codes from the SNOMED CT UK coding system that:
\nidentify a substance or pharmaceutical or biologic product that the patient has an allergy or intolerance to
\nprovide a degrade of information about a drug or non-drug allergy
\nWhere no dm+d or SNOMED CT coded information is available, a specific code from the nullFlavor Code System can be used instead to indicate this.
\n \n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text field to be used if no code is available", "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", "implementationGuidance": "A description of the manifestation of the allergic or adverse reaction experienced by the person. For example, skin rash.", "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", "implementationGuidance": "The coded value for description of reaction.", "description": "The coded value for description of reaction.", "valueSets": "FHIR value set: Allergy manifestation
SNOMED CT: - ^1127581000000103 |Health issues simple reference set| or 196411000000103 | Transfer-degraded record entry (record artifact) |
"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text field to be used if no code is available", "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": "Date and time when manifestations showed e.g could be at home a few days earlier than the contact", "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", "implementationGuidance": "A description of the severity of the reaction.", "description": "A description of the severity of the reaction.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for severity", "description": "The coded value for severity", "valueSets": "FHIR value set: Severity
"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text field to be used if no code is available", "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", "implementationGuidance": "A description of the certainty that the stated causative agent caused the allergic or adverse reaction.", "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", "implementationGuidance": "The coded value for certainty.", "description": "The coded value for certainty.", "valueSets": "FHIR value set : - Certainty \n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text field to be used if no code is available", "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", "implementationGuidance": "The route the person was exposed to the substance", "description": "The route the person was exposed to the substance", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for route of exposure", "description": "The coded value for route of exposure", "valueSets": "\nRefer to the UK Core Substance or Product Administration Route
\nSNOMED CT: - ^999000051000001100 |ePrescribing route of\n administration simple reference set|
\n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text field to be used if no coded text available", "description": "Free text field to be used if no coded text available", "valueSets": "\nThis section allows for the recording of the results of any assessments completed. This may include, but is not limited to, depression screening tools such as PHQ-9 or GAD-7 and alcohol screening tools such as AUDIT. The results of any assessments completed must be displayed under this section.
This is an example list\n of assessment scales that may be used in the maternity setting and may be recorded under this section:
Adverse Childhood Experiences (ACEs) Assessments
Alarm Distress Baby Scale (ADBB)
Alcohol Screening Tool - AUDIT - C
Anxiety Identification Questions
Bishop's\n Score
Brief Mood Introspection Scale (BMIS)
Clinical Outcomes in Routine Evaluation 10 (CORE-10)
Clinical Outcomes in Routine Evaluation \u2013 Outcome Measure (CORE-OM)
Connected
Edinburgh Postnatal Depression Scale (EPDS)
Generalised Anxiety Disorder\n Questionnaire
Health of the Nation Outcome Scales (HoNOS)
Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA)
Infant CARE-Index
London Measure of Unplanned Pregnancy
Maternity Early Warning Scores (MEWS)
Maternity Pathway\n Indicator
Modified Early Obstetric Warning Score (MEOWS)
Mood and Feelings Questionnaire
National Institute of Child Health and Human Development (NICHD)
Newborn Early Warning Track and Trigger-2 (NEWTT-2)
Patient Health Questionnaire-9
Postpartum Bonding\n Questionnaire (PBQ)
Post-Traumatic Stress Disorder Impacts of Events Revised Scale
Risk Assessments for Venous Thromboembolism Prophylaxis
Rockwood Clinical Frailty Scale
The Parent Infant Interaction Observation Scale (PIIOS)
Venous Thromboembolism Risk Assessment\n Tool
Whooley Questions for Depression Screening
A clinician may wish to assess the woman / birthing person for digital poverty with the following Connected Care Questions:
Can you download apps, make calls, and send text messages on your mobile device?
Are you able to access the\n internet at home?
Are you able to access the internet away from home?
This section may be used to capture the woman / birthing person's birth experiences. If a structured survey is used, then this can be captured in the structured assessment section.
\n ", "description": "This is the unstructured assessments record entry. There may be 0 to many record entry/entries under a section. Each record entry is made up of a number of elements or data items.
", "informationType": "Event.Record", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Assessment type", "implementationGuidance": "The type of the assessment e.g. social care needs assessment.", "description": "The type of the assessment e.g. social care needs assessment.", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Assessment scale", "implementationGuidance": "Assessment scale used. Content could include scale name, date and time of assessment and values recorded, including overall score. Format of assessment would be determined locally and may be tabular.", "description": "Assessment scale used. Content could include scale name, date and time of assessment and values recorded, including overall score. Format of assessment would be determined locally and may be tabular.
", "valueSets": "Free Text.
"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Assessment summary", "implementationGuidance": "The summary of the assessment", "description": "The summary of the assessment", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "250"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Structured assessment record entry", "implementationGuidance": "\nThis section may be used to capture the woman / birthing person's birth experiences, if captured via a structured survey or other assessment. If a structured survey is not used, then this can be captured in the structured assessment section.
\n ", "description": "This is the structured assessments record entry. There may be 0 to many record entry/entries under a section. Each record entry is made up of a number of elements or data items.
", "informationType": "\n <p>Event.Record</p> \n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Structured assessment", "implementationGuidance": "Details of the structured assessment.", "description": "Details of the structured assessment.", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Structured assessment name", "implementationGuidance": "Structured assessment name e.g. New York Heart Failure, Glasgow Coma scale, Activities of Daily Living (ADL) etc.", "description": "Structured assessment name e.g. New York Heart Failure, Glasgow Coma scale, Activities of Daily Living (ADL) etc.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for structured assessment name.\u00a0", "description": "The coded value for structured assessment name.\u00a0", "valueSets": "\nThe overall structured assessment score, e.g. health status assessment, mental health evaluation, or functional capacity assessment.
", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for assessment score.\u00a0", "description": "The coded value for assessment score.\u00a0", "valueSets": "\nThis section should be used to record the details of any healthcare professional that has provided care to the mother/birthing person.
", "description": "Details of health care professional
", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional record entry", "implementationGuidance": "This is a health care professional record entry. There may be 0 to many record entries under a section.", "description": "This is a health care professional record entry. There may be 0 to many record entries under a section.
", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier type", "implementationGuidance": "The type of professional identifier", "description": "The type of professional identifier
", "valueSets": "NHS data dictionary :- PROFESSIONAL REGISTRATION BODY
", "valueDomain": [{"type": "string"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "implementationGuidance": "The unique identification number or code assigned to the professional, based on the identifier type.", "description": "The unique identification number or code assigned to the professional, based on the identifier type.
", "valueSets": "NHS data dictionary :- CARE\u00a0PROFESSIONAL\u00a0IDENTIFIER
", "valueDomain": [{"type": "string"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "implementationGuidance": "The name of the health care professional", "description": "The name of the health care professional
", "valueSets": "NHS data dictionary : - Person full name
", "valueDomain": [{"type": "string"}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "implementationGuidance": "The role of the health care professional", "description": "The role of the health care professional
", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "Coded value for role of health care professional", "description": "Coded value for role of health care professional
", "valueSets": "NHS Data Dictionary: - CARE PROFESSIONAL ROLE
"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text field to be used if no code is available", "description": "Free text field to be used if no code is available
", "valueSets": "Free text
", "valueDomain": [{"type": "string"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "implementationGuidance": "The grade of the health care professional", "description": "The grade of the health care professional
", "valueDomain": [{"type": "string"}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Specialty", "implementationGuidance": "The specialty of the health care professional", "description": "The specialty of the health care professional
", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for the specialty of the health care professional", "description": "The coded value for the specialty of the health care professional
", "valueSets": "NHS data dictionary :- CARE PROFESSIONAL MAIN SPECIALTY CODE
"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text field to be used if no code is available", "description": "Free text field to be used if no code is available
", "valueSets": "Free text
", "valueDomain": [{"type": "string"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation", "implementationGuidance": "The name of the organisation the health professional works for", "description": "The name of the organisation the health professional works for
", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "Coded entry for the organisation", "description": "Coded entry for the organisation
", "valueSets": "NHS data dictionary : - Organisations code of provider
"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text field to be used if no code is available", "description": "Free text field to be used if no code is available
", "valueSets": "Free text
", "valueDomain": [{"type": "string"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "implementationGuidance": "Contact details of the health care professional", "description": "Contact details of the health care professional
", "valueDomain": [{"type": "string"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contacts with professionals", "implementationGuidance": "\nA record should be provided of the details of each professional contact with the woman / birthing person. This may include home visits, hospital outpatient visits and clinic visits.
\nThis section includes the ability to add additional professionals included in the contact and any additional persons accompanying the woman / birthing person.
\nThe 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).
\n ", "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": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional record entry", "implementationGuidance": "This is a health care professional record entry. There may be 0 to many record entries under a section.", "description": "This is a health care professional record entry. There may be 0 to many record entries under a section.
"}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Other health and care professionals present", "implementationGuidance": "\nThe name, role of the additional individuals or team members including consultant(s), nurse consultant(s), allied health professional(s), social worker(s).
\n ", "description": "Other health and care professionals present", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "implementationGuidance": "Name of the other care professional present", "description": "\nName of the other care professional present
\n ", "valueDomain": [{"type": "string"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "implementationGuidance": "Role of the other care professional", "description": "\nRole of the other care professional
\n ", "valueSets": "\nAlignment to the workforce dataset NHS Occupation codes primarily is advised. Where no code is available, free text may be used.
\nNational Workforce Data Set (NWD) NHS Occupation codes are found here: -\u00a0https://digital.nhs.uk/data-and-information/data-collections-and-data-sets/data-sets/national-workforce-data-set-nwd-and-nhs-occupation-codes. To access the list of roles, download the 'NWD dataset specification' using the link on the page.
\nThe Staff Groups and Job Roles are listed in the \u2018NWD Class & Codes Appendix\u2019 tab of the attached NWD Dataset from row 640. The 'Staff Group' and 'Job Role' segments are contained in one field named 'Job' which work together e.g. Staff Group = Nursing & Midwifery Registered and Job Role = Staff Nurse.
\n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier type", "implementationGuidance": "The type of professional identifier. For example, General Medical Council (GMC); Nursing and Midwifery Council\u00a0(NMC) numbers.", "description": "\nThe type of professional identifier. For example, General Medical Council (GMC); Nursing and Midwifery Council\u00a0(NMC) numbers.
\n ", "valueSets": "\nNationally or internationally maintained code system(s) (see implementation guidance).
\n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "implementationGuidance": "Professional identifier for the professional completing the record e.g. General Medical Council (GMC), Nursing Medical Council (NMC) number etc, or the personal identifier used by the local organisation.", "description": "\nProfessional identifier for the professional completing the record e.g. General Medical Council (GMC), Nursing Medical Council (NMC) number etc, or the personal identifier used by the local organisation.
\n ", "valueSets": "\nFree text
\n ", "valueDomain": [{"type": "string"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional record entry", "implementationGuidance": "This is a health care professional record entry. There may be 0 to many record entries under a section.", "description": "This is a health care professional record entry. There may be 0 to many record entries under a section.
"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Person accompanying patient", "implementationGuidance": "Identify, where clinically relevant, others accompanying the patient, e.g. parent, relative, friend. Includes: Name, Relationship, role (e.g. informal carer).", "description": "Identify, where clinically relevant, others accompanying the patient, e.g. parent, relative, friend. Includes: Name, Relationship, role (e.g. informal carer).", "valueSets": "NHS data dictionary : - Person full name \n ", "valueDomain": [{"type": "string", "property": [{"maxLength": "70"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Use of an interpreter", "implementationGuidance": "An indicator to record whether an interpreter was used at a care contact. If yes, records whether a professional interpreter, family member / friend, or other person was used for the purposes of communication. If no, records whether an interpreter was not required or did not attend.", "description": "An indicator to record whether an interpreter was used at a care contact. If yes, records whether a professional interpreter, family member / friend, or other person was used for the purposes of communication. If no, records whether an interpreter was not required or did not attend.", "valueSets": "NHS data dictionary : - Interpreter present at care contact indication code \n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Reason for service", "implementationGuidance": "The reason why the person has been offered the service", "description": "The reason why the person has been offered the service", "valueSets": "\nFree text
\n ", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Presenting complaint or issue", "implementationGuidance": "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.", "description": "\nType of contact e.g. GP consultation, outpatient attendance
", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "Coded value for contact type", "description": "\nCoded value for contact type
\n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text if the coded value for type of contact is not available e.g. GP consultation, outpatient attendance", "description": "\nFree text if the coded value for type of contact is not available e.g. GP consultation, outpatient attendance
\n ", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Appointment type", "implementationGuidance": "The type of appointment that the individual had with the professional e.g. physiotherapy appointment, GP appointment", "description": "The type of appointment that the individual had with the professional e.g. physiotherapy appointment, GP appointment
", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "Coded value for the appointment type", "description": "Coded value for the appointment type
", "valueSets": "SNOMED CT
<308817005 | Appointment status (finding) | or
<749001000000101 | Appointment (record artifact) |
"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text to be used if no coded value available", "description": "\nFree text to be used if no coded value available
\n ", "valueDomain": [{"type": "text"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Audio or video recording of the conversation", "implementationGuidance": "Audio or video recording of the conversation cluster.", "description": "Audio or video recording of the conversation cluster.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Audio or visual recording made", "implementationGuidance": "An indicator to record if an audio or video recording was made of the conversation.", "description": "An indicator to record if an audio or video recording was made of the conversation.", "valueSets": "SNOMED CT : - 431315003 |Audio recording of patient interview (procedure)| or 282733006 |Video recording of patient interview (procedure)|."}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Consent for audio or video recording of the conversation", "implementationGuidance": "This is a record of consent for audio or visual recording of the conversation.", "description": "This is a record of consent for audio or visual recording of the conversation.", "valueSets": "Free text.", "valueDomain": [{"type": "text"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Copy of video or audio recording", "implementationGuidance": "The conversation recording should be stored as a video/audio multimedia file or as a transcript (free text).", "description": "The conversation recording should be stored as a video/audio multimedia file or as a transcript (free text).", "valueSets": "Free text or multimedia file.", "valueDomain": [{"type": "complex"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Consultation method", "implementationGuidance": "Consultation method used e.g. face to face, telephone", "description": "Consultation method used e.g. face to face, telephone", "valueSets": "NHS data dictionary - Consultation mechanism \n ", "valueDomain": [{"type": "string", "property": [{"maxLength": "2"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Specialty", "implementationGuidance": "The specialty e.g. physiotherapy, oncology, mental health etc", "description": "The specialty e.g. physiotherapy, oncology, mental health etc", "valueSets": "NHS data dictionary - Activity treatment function code \n ", "valueDomain": [{"type": "string", "property": [{"maxLength": "3"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation name", "implementationGuidance": "The name, including the identifier, of the organisation providing the service", "description": "The name, including the identifier, of the organisation providing the service", "valueSets": "NHS data dictionary : - Organisation name \n ", "valueDomain": [{"type": "string", "property": [{"maxLength": "255"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation address", "implementationGuidance": "The name of the organisation, including the identifier.", "description": "The name of the organisation, including the identifier.", "valueSets": "NHS data dictionary : - Organisation address \n ", "valueDomain": [{"type": "string", "property": [{"maxLength": "175"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Organisation contact details", "implementationGuidance": "The contact details of the organisation. For example a phone number, NHSmail address etc. Contact details are used to resolve queries about the record entry.", "description": "The contact details of the organisation. For example a phone number, NHSmail address etc. Contact details are used to resolve queries about the record entry.", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Service", "implementationGuidance": "The service that was provided.", "description": "The service that was provided.", "valueSets": "\n \n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Outcome of contact", "implementationGuidance": "This records the outcome of the contact.", "description": "This records the outcome of the contact.", "valueSets": "\nLinking Fetus Records to Baby Records Post Birth:
\nFor single fetus pregnancies, a link can be made between the fetus details and associated test information with the baby once born.
For multiple fetus pregnancies, clinical input is required to ensure the fetus details are associated with correct baby post natal.
Group containing fetus details
\n ", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Local fetal identifier", "implementationGuidance": "Local identifier for the fetus", "description": "Local identifier for the fetus
", "valueSets": "\nIdentifier
\n ", "valueDomain": [{"type": "identifier"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Fetal order", "implementationGuidance": "Fetal order", "description": "Fetal order", "valueSets": "\nFetal order
\n ", "valueDomain": [{"type": "count"}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Fetal problems diagnosed before birth", "implementationGuidance": "Fetal problems diagnosed before birth", "description": "Fetal problems diagnosed before birth", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Problem list", "implementationGuidance": "A summary of the problems that require investigation or treatment.", "description": "A summary of the problems that require investigation or treatment.", "informationType": "<p>Event.Record</p>"}]}]}, {"type": "group", "minimumMultiplicity": "1", "maximumMultiplicity": "*", "mro": "M", "name": "Birth and baby details", "implementationGuidance": "\nThis section is designed to capture information about the fetus/baby which is recorded on the woman / birthing person\u2019s record. Not all systems currently record this information against a woman / birthing person as it is information that relates to the baby/fetus following birth. This information is modelled against the person and does not mean that the\n current way of recording this information needs to stop. This information will still be required as part of the Maternity Services Data Set (MSDS).
\nThis section allows for details about the outcome of the birth to be recorded. Note all these items must also be recorded on the baby's record. This should be a fully separate digital child health record (https://theprsb.org/standards/healthychildrecordstandard/) stored under the baby's NHS Number. However local systems may provide a link between the two records.
\nDetails recorded on the fetus/baby record following birth should conform with the Healthy Child Record Standard (https://theprsb.org/standards/healthychildrecordstandard/). However, it is recommended that additional elements such as the suspected\n congenital abnormality indicator and APGAR assessment component scores should also be recorded on the baby\u2019s record.
\nGestation at birth should be stored in days, but displayed in weeks and days.
\nWhen using SNOMED CT terminology to record details pertaining to the infant on the woman / birthing person\u2019s record it is important to adhere to the principles set out in the SNOMED CT Technical Implementation Guide provided by SNOMED International. Below is an example of an expression included within a contextual wrapper which allows information to be\n recorded in a way that takes account of contextual information. It is important to take this into account when recording and sharing information that does not directly pertain to the subject of the record. See example below:
\n243796009 |Situation with explicit context (situation)|
\n{
\n246090004 |Associated finding (attribute)| = [specified concept or from refset],
\n408732007 |Subject relationship context (attribute)| = 444192005 |Child of subject (person)|
\n}
\nAny investigations recorded against the fetus following a stillbirth, including postmortems, should be recorded under this section. All investigations requested for a live birth must be recorded on the baby record.
\nAs a principle, if there is a difference in an element recorded within this section based around the fetus in the instances of a multiple pregnancy, then these fields should be repeated per fetus.
\nThe baby and birth details section should not be removed from the woman/birthing person's record, even if information from this section is transferred to the baby's record.
\nGroup containing birth and baby details
\n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Birth details", "implementationGuidance": "Pregnancy outcome delivery and birth", "description": "Pregnancy outcome delivery and birth", "informationType": "\n <p>Event.Record</p> \n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Birth details record entry", "implementationGuidance": "Birth details record entry", "description": "Birth details record entry", "concept": [{"type": "group", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "M", "name": "Birth Outcome", "implementationGuidance": "\nThis element should be used to record the outcome of the birth, regardless of whether the baby is born alive.
\nIt is recognised that some current maternity systems create a pregnancy flag once an estimated delivery date is entered. Systems must ensure that this is amended if a pregnancy is aborted or terminated.
\nWhere a birth outcome is not a live birth, it is recommended that a local flag should be displayed in the record so that it can easily be seen, and so prevent situations where a woman / birthing person who has had a miscarriage presents to a service whose records show that she is they are still pregnant.
\nFetal losses must be linked to the \u2018fetal identifier\u2019. It is recommended that a local flag should be used to highlight fetal losses under the \u2018birth outcome\u2019 element that make it clear that there is not a birth.
\nThere should be a local agreement on early pregnancy loss information sharing and integration between early pregnancy assessment/pregnancy related gynaecology and maternity services to allow for information transfer/sharing.
\nThe element \u2018Birth Outcome\u2019 relates to the birth outcome and not the fetal outcome which is recorded on the baby\u2019s record. Therefore, there may be more than one pregnancy outcome recorded.
\nThe outcome of the birth
\n \n ", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The list of SNOMED codes for birth outcome is captured in the 'supporting SNOMED code' document on the PRSB website
If \"Stillbirth\" is the option picked from the valueset, then this should be clearly indicated in the woman / birthing person's record so that healthcare professionals can see the history of stillbirths.
Coded value for birth outcome
\n ", "valueSets": "\nSNOMED CT
\n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "\nUse this element detail any pertinent information regarding a second trimester miscarriage.
\n ", "description": "\nFree text for use if no coded value available
\n ", "valueSets": "\nFree text
\n ", "valueDomain": [{"type": "text"}]}]}, {"type": "group", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "M", "name": "Location of Birth", "implementationGuidance": "The place the baby was born.", "description": "The place the baby was born.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for location of birth.", "description": "The coded value for location of birth.", "valueSets": "NHS Data Dictionary: -\u00a0 Site Code (of Actual Place of Delivery) \nBirth place type
\n ", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The type of place in which the baby was born (e.g. Private health facility, domestic address, NHS hospital, midwifery led unit etc. )", "description": "The type of place in which the baby was born (e.g. Private health facility, domestic address, NHS hospital, midwifery led unit etc. )", "valueSets": "\nCoded value
\n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text for use if coded value not available", "description": "\nFree text for use if coded value not available
\n ", "valueSets": "\nFree text
\n ", "valueDomain": [{"type": "text"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Birth place type comment", "implementationGuidance": "Birth place type comment", "description": "Birth place type comment", "valueSets": "\nFree text
\n ", "valueDomain": [{"type": "text"}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Type of birth attempted", "implementationGuidance": "Type of birth attempted", "description": "Type of birth attempted", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Classification of urgency for attempted birth", "implementationGuidance": "Classification of urgency for attempted birth", "description": "Classification of urgency for attempted birth", "valueSets": "\nFree text
\n ", "valueDomain": [{"type": "text"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date / time of decision for type of birth attempted", "implementationGuidance": "Date / time of decision for type of birth attempted", "description": "Date / time of decision for type of birth attempted", "valueSets": "\nDate and time
\n ", "valueDomain": [{"type": "datetime"}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Type of birth attempted decision - Healthcare Professional", "implementationGuidance": "Healthcare Professional who made the type of birth attempted decision -\u00a0", "description": "\nHealthcare Professional who made the type of birth attempted decision -\u00a0
\n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional record entry", "implementationGuidance": "This is a health care professional record entry. There may be 0 to many record entries under a section.", "description": "This is a health care professional record entry. There may be 0 to many record entries under a section.
"}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Birth (Procedure)", "implementationGuidance": "Birth (Procedure)", "description": "Birth (Procedure)", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Procedure", "implementationGuidance": "The therapeutic or diagnostic procedure performed. Includes both psychological and medical therapies and procedures. Complementary or alternative procedures should be recorded here.", "description": "The therapeutic or diagnostic procedure performed. Includes both psychological and medical therapies and procedures. Complementary or alternative procedures should be recorded here.
"}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Other professional participants", "implementationGuidance": "Other professional participants present during the attempted birth", "description": "\nOther professional participants present during the attempted birth
\n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Birth assisted by", "implementationGuidance": "Care professional who assisted during the Birth attempt", "description": "\nCare professional who assisted during the Birth attempt
\n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional record entry", "implementationGuidance": "This is a health care professional record entry. There may be 0 to many record entries under a section.", "description": "This is a health care professional record entry. There may be 0 to many record entries under a section.
"}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Birth supervised by", "implementationGuidance": "Care professional who supervised the birth attempt", "description": "\nCare professional who supervised the birth attempt
\n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional record entry", "implementationGuidance": "This is a health care professional record entry. There may be 0 to many record entries under a section.", "description": "This is a health care professional record entry. There may be 0 to many record entries under a section.
"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Episiotomy (Procedure)", "implementationGuidance": "Episiotomy details", "description": "Episiotomy details", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Procedure", "implementationGuidance": "The therapeutic or diagnostic procedure performed. Includes both psychological and medical therapies and procedures. Complementary or alternative procedures should be recorded here.", "description": "The therapeutic or diagnostic procedure performed. Includes both psychological and medical therapies and procedures. Complementary or alternative procedures should be recorded here.
"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Head born", "implementationGuidance": "Head born observations", "description": "\nHead born observations
\n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Observations", "implementationGuidance": "The record of essential physiological measurements, e.g., heart rate, blood pressure, temperature, pulse, height, weight, respiratory rate, oxygen saturation.", "description": "The record of essential physiological measurements, e.g., heart rate, blood pressure, temperature, pulse, height, weight, respiratory rate, oxygen saturation.", "informationType": "\n <p>Event.Record</p> \n "}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Problems during birth", "implementationGuidance": "Problems during birth", "description": "Problems during birth", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Problem list", "implementationGuidance": "A summary of the problems that require investigation or treatment.", "description": "A summary of the problems that require investigation or treatment.", "informationType": "<p>Event.Record</p>"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Level of postnatal care for baby", "implementationGuidance": "Level of postnatal care for baby", "description": "Level of postnatal care for baby", "valueSets": "\nFree text
\n ", "valueDomain": [{"type": "text"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Baby Details", "implementationGuidance": "Birth Details", "description": "Birth Details", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Baby Details record entry", "implementationGuidance": "Baby Details record entry", "description": "Baby Details record entry", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Baby Identifier", "implementationGuidance": "Baby identifier details", "description": "Baby identifier details", "valueSets": "\nIdentifier
\n ", "valueDomain": [{"type": "identifier"}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Multiple birth order", "implementationGuidance": "Multiple birth order", "description": "Multiple birth order", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Observations", "implementationGuidance": "The record of essential physiological measurements, e.g., heart rate, blood pressure, temperature, pulse, height, weight, respiratory rate, oxygen saturation.", "description": "The record of essential physiological measurements, e.g., heart rate, blood pressure, temperature, pulse, height, weight, respiratory rate, oxygen saturation.", "informationType": "\n <p>Event.Record</p> \n "}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Baby demographics", "implementationGuidance": "The baby's details.", "description": "The baby's details.
", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person Demographics", "implementationGuidance": "Details of the person's name", "description": "Details of the person's name", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person first name", "implementationGuidance": "The first name(s) of the person. This includes middle names.", "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": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Preferred first name", "implementationGuidance": "The persons preferred first name.", "description": "\nThe persons preferred first name.
\n ", "valueDomain": [{"type": "string"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person family name", "implementationGuidance": "The family name or surname of the person", "description": "The family name or surname of the person", "valueSets": "NHS data dictionary : - Person family name \nNHS data dictionary : - Person full name
", "valueDomain": [{"type": "string", "property": [{"maxLength": "70"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Title", "implementationGuidance": "Person's title.", "description": "Person's title.
", "valueSets": "NHS data dictionary : - Patient title
", "valueDomain": [{"type": "string", "property": [{"maxLength": "35"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person name suffix", "implementationGuidance": "A textual suffix that may be added to the end of a person's name, for example, OBE, MBE, BSc, JP, GM, etc.", "description": "A textual suffix that may be added to the end of a person's name, for example, OBE, MBE, BSc, JP, GM, etc.
", "valueSets": "NHS data dictionary : - Person name suffix
", "valueDomain": [{"type": "string", "property": [{"maxLength": "35"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person full name", "implementationGuidance": "The full name of the person in text representation.", "description": "The full name of the person in text representation.", "valueSets": "NHS data dictionary : - Person full name
", "valueDomain": [{"type": "string", "property": [{"maxLength": "70"}]}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Ethnicity", "implementationGuidance": "The ethnicity of the person as specified by the person.", "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": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Phenotypic sex", "implementationGuidance": "Phenotypic sex", "description": "Phenotypic sex", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "Phenotypic sex at birth", "description": "\nPhenotypic sex at birth
\n ", "valueSets": "\nNHS data dictionary: - person phenotypic sex
\n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text", "description": "Free text", "valueDomain": [{"type": "text"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "NHS Number", "implementationGuidance": "The unique identifier for a woman within the NHS in England and Wales.", "description": "The unique identifier for a woman within the NHS in England and Wales.", "valueSets": "\nNHS data dictionary:- NHS number
\n ", "valueDomain": [{"type": "text"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "NHS number status indicator", "implementationGuidance": "Provides an indication of the reliability of an NHS Number.", "description": "Provides an indication of the reliability of an NHS Number.", "valueDomain": [{"type": "string", "property": [{"maxLength": "2"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Other NHS identifier group ", "implementationGuidance": "NHS identifier other than NHS number.", "description": "NHS identifier other than NHS number.
", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Other NHS identifier", "implementationGuidance": "Details of the other NHS identifier required to be held against the person's record.", "description": "Details of the other NHS identifier required to be held against the person's record.
", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for other NHS identifier.", "description": "The coded value for other NHS identifier.
", "valueSets": "NHS Data Dictionary :- HEALTH AND CARE NUMBER
NHS Data Dictionary :- COMMUNITY HEALTH INDEX NUMBER
", "valueDomain": [{"type": "string"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text", "description": "Free text
", "valueDomain": [{"type": "text"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Type of other NHS identifier", "implementationGuidance": "Details that describe the type of NHS identifier being used. Country specific or local identifier, e.g. Community Health Index (CHI) in Scotland.", "description": "Details that describe the type of NHS identifier being used. Country specific or local identifier, e.g. Community Health Index (CHI) in Scotland.
", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for the type of other NHS identifier e.g., CHI code.", "description": "The coded value for the type of other NHS identifier e.g., CHI code.
"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text", "description": "Free text", "valueDomain": [{"type": "string"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Other NHS identifier", "implementationGuidance": "Other NHS identifier other than NHS number", "description": "\nOther NHS identifier other than NHS number
\n ", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "Coded value for other NHS identifier", "description": "\nCoded value for other NHS identifier
\n ", "valueSets": "\nNHS data dictionary: -\u00a0Local patient identifier(extended), Health and care number (NI only),\u00a0Community health index number\u00a0(Scotland only)
\n ", "valueDomain": [{"type": "text"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free tex for when coded value is not available", "description": "\nFree tex for when coded value is not available
\n ", "valueDomain": [{"type": "text"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date & Time of birth", "implementationGuidance": "The date and time of birth of the baby.", "description": "The date and time of birth of the baby.", "valueSets": "\nDate and time
\n ", "valueDomain": [{"type": "datetime"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date and time of death", "implementationGuidance": "Date and time of death", "description": "Date and time of death", "valueSets": "\nDate and time
\n ", "valueDomain": [{"type": "datetime"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Postnatal assessments", "implementationGuidance": "Details of routine postnatal assessments and observations regarding the baby.", "description": "Details of routine postnatal assessments and observations regarding the baby.
", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Birth weight", "implementationGuidance": "Birth weight", "description": "Birth weight", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Observations", "implementationGuidance": "The record of essential physiological measurements, e.g., heart rate, blood pressure, temperature, pulse, height, weight, respiratory rate, oxygen saturation.", "description": "The record of essential physiological measurements, e.g., heart rate, blood pressure, temperature, pulse, height, weight, respiratory rate, oxygen saturation.", "informationType": "\n <p>Event.Record</p> \n "}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Length of gestation at birth", "implementationGuidance": "Gestation in weeks and days (at birth).", "description": "Gestation in weeks and days (at birth).", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Observations", "implementationGuidance": "The record of essential physiological measurements, e.g., heart rate, blood pressure, temperature, pulse, height, weight, respiratory rate, oxygen saturation.", "description": "The record of essential physiological measurements, e.g., heart rate, blood pressure, temperature, pulse, height, weight, respiratory rate, oxygen saturation.", "informationType": "\n <p>Event.Record</p> \n "}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Spontaneous respiration", "implementationGuidance": "Spontaneous respiration received by the baby", "description": "\nSpontaneous respiration received by the baby
\n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Examination findings", "implementationGuidance": "Examination findings", "description": "Examination findings"}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Rhesus status", "implementationGuidance": "Baby's rhesus status", "description": "\nBaby's rhesus status
\n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Investigation results ", "implementationGuidance": "Investigation results", "description": "\nInvestigation results
\n "}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Physical problems detected at birth", "implementationGuidance": "Physical problems detected at birth", "description": "Physical problems detected at birth", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Problem list record entry", "implementationGuidance": "This is a problem list record entry. \n \n There may be 0 to many record entries under problem list. \n \n Each record entry is made up of a number of elements or data items.", "description": "This is a problem list record entry.The list of SNOMED codes that support the Digital Maternity Record Standard.can be found on the PRSB website here.
", "description": "Congenital abnormalities", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Problem list record entry", "implementationGuidance": "This is a problem list record entry. \n \n There may be 0 to many record entries under problem list. \n \n Each record entry is made up of a number of elements or data items.", "description": "This is a problem list record entry.NHS data dictionary : - APGAR SCORE (1 MINUTE)
", "description": "Details of the person's assessments"}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "APGAR Assessment 5 minutes", "implementationGuidance": "APGAR Assessment 5 minutes", "description": "APGAR Assessment 5 minutes", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Assessments", "implementationGuidance": "NHS data dictionary : - APGAR SCORE (5 MINUTES)
", "description": "Details of the person's assessments"}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "APGAR Assessment 10 minutes", "implementationGuidance": "APGAR Assessment 10 minutes", "description": "APGAR Assessment 10 minutes", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Assessments", "implementationGuidance": "NHS data dictionary : - APGAR SCORE (10 MINUTES)
", "description": "Details of the person's assessments"}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Feeding details", "implementationGuidance": "Feeding details", "description": "Feeding details", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date and time of baby's first feed", "implementationGuidance": "Date and time of babies first feed", "description": "Date and time of babies first feed", "valueSets": "\nDate and time
\n ", "valueDomain": [{"type": "datetime"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Baby's first feed type", "implementationGuidance": "Baby's first feed type - Maternal breast milk, donor breast milk, not breast milk", "description": "\nBaby's first feed type - Maternal breast milk, donor breast milk, not breast milk
\n ", "valueSets": "\nFree text
\n ", "valueDomain": [{"type": "text"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Put To Breast", "implementationGuidance": "Whether or not the baby was put to the breast.", "description": "Whether or not the baby was put to the breast.", "valueSets": "\nBoolean: yes or no
\n ", "valueDomain": [{"type": "boolean"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Skin to skin contact with mother in first hour", "implementationGuidance": "Skin to skin contact with mother in first hour", "description": "Skin to skin contact with mother in first hour", "valueSets": "\nBoolean Yes or no
\n ", "valueDomain": [{"type": "boolean"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Postnatal care", "implementationGuidance": "Details of postnatal care provided to the baby.", "description": "Details of postnatal care provided to the baby.
", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Neonatal resuscitation", "implementationGuidance": "Neonatal resuscitation received by the baby", "description": "\nNeonatal resuscitation received by the baby
\n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Procedure", "implementationGuidance": "The therapeutic or diagnostic procedure performed. Includes both psychological and medical therapies and procedures. Complementary or alternative procedures should be recorded here.", "description": "The therapeutic or diagnostic procedure performed. Includes both psychological and medical therapies and procedures. Complementary or alternative procedures should be recorded here.
"}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Investigations requested", "implementationGuidance": "Details of any investigations requested", "description": "Details of any investigations requested", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Investigations requested", "implementationGuidance": "Details of any investigations requested", "description": "Details of any investigations requested"}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Stillbirth investigations requested", "implementationGuidance": "Stillbirth investigations requested", "description": "Stillbirth investigations requested", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Investigation requested", "implementationGuidance": "The date on which the investigation was requested", "description": "The investigation that is requested. The investigation may refer to an individual test or a group of related tests or broader investigation required (so the investigator can determine the appropriate tests)"}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Post natal care", "implementationGuidance": "Post natal care", "description": "Post natal care", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Neonatal care transfer date and time", "implementationGuidance": "Neonatal care transfer date and time", "description": "Neonatal care transfer date and time", "valueSets": "\nDate and time
\n ", "valueDomain": [{"type": "datetime"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Critical care transfer date and time", "implementationGuidance": "Critical care transfer date and time", "description": "Critical care transfer date and time", "valueSets": "\nDate and time
\n ", "valueDomain": [{"type": "datetime"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Critical care type", "implementationGuidance": "Critical care type", "description": "Critical care type", "valueSets": "\nFree text
\n ", "valueDomain": [{"type": "text"}]}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date of discharge from delivery hospital", "implementationGuidance": "Date of discharge from delivery hospital", "description": "Date of discharge from delivery hospital", "valueSets": "\nDate
\n ", "valueDomain": [{"type": "date"}]}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Examination findings", "implementationGuidance": "\nThis section includes any findings from an examination conducted by a healthcare professional.
\nThe examination findings section is specifically designed for healthcare professionals who work within the maternity setting who wish to record the examinations of various biological systems, e.g. cardiovascular, head and neck etc.
\nEach record of an \u2018Examination finding\u2019 should include a named examination and associated findings, which may include both coded and narrative elements.
\nInformation systems should link an examination finding to a diagnosis, where appropriate.
\nA number of fields are marked as required but will be mandatory at some appointments. It is up to local settings to decide when a required element is upgraded to mandatory.
\nCrown-rump length must be measurable to one decimal place.
\nFetal heart rate indication and method for measuring should be completed.
\nThis section will include details of the damage to the vagina/cervix which may require surgical repair.
\nFetal examinations recorded under this heading must be linked to the \u2018fetal identifier\u2019.
\nColour / Neuro /Feeds should be captured as examination findings for NEWTT2.
\nFree text
\n ", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Examination finding - Postcoordinated", "implementationGuidance": "Examination finding - Postcoordinated", "description": "Examination finding - Postcoordinated", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Body site", "implementationGuidance": "The body site of the examination finding.\u00a0", "description": "The body site of the examination finding.\u00a0", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for body site.\u00a0", "description": "The coded value for body site.\u00a0", "valueSets": "SNOMED CT."}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text field to be used if no code is available", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Laterality", "implementationGuidance": "The laterality of the examination finding (left or right or bilateral).", "description": "The laterality of the examination finding (left or right or bilateral).", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for laterality.", "description": "\nCoded Value for examination findings
\n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text to be used when coded value is not available", "description": "\nFree text to be used when coded value is not available
\n ", "valueDomain": [{"type": "text", "property": [{"minLength": "0", "maxLength": "150"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Severity", "implementationGuidance": "The severity of the examination finding.\u00a0", "description": "The severity of the examination finding.\u00a0", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for severity.\u00a0", "description": "The coded value for severity.\u00a0", "valueSets": "SNOMED CT."}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text field to be used if no code is available", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Examination findings - Precoordinated", "implementationGuidance": "The record of findings from the examinations performed.", "description": "The record of findings from the examinations performed.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for examination findings.", "description": "The coded value for examination findings.", "valueSets": "\nFree text
\n ", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Observations", "implementationGuidance": "\nThis section allows for the recording of any observations recorded against the woman / birthing person.
\nSNOMED CT has been used so as to not limit how the observations are measured and recorded. For example, the model allows all SNOMED CT under the parent Blood pressure (observable entity) | 75367002 to be used.
\nWhere a SNOMED CT observable entity code is recorded in relation to the quality/property observed, an associated paired value and UCUM unit of measurement must also be recorded and accompany the recorded code.
\nAn observation for \u2018BMI\u2019 must be populated if a height and weight are recorded.
\nBoth the diastolic and systolic elements of the blood pressure reading of a woman / birthing person must be recorded together.
\nThis section is where symphysis fundal height may be recorded.
\nThis section can be used to capture both the family history of the woman / birthing person, and the fetal family history. Where a known donor is present, the system should prioritise the contact information of the individuals listed under the personal contacts section, rather than the individuals within the family history section.
\nThis section should be used to record any relevant family/genetic history of the fetus(es). Use the person identifier, person identifier type, and fetal order elements to distinguish whose family/genetic history is being recorded (i.e., the mother / birthing person or a fetus).
\n\u2018Family\u2019 in this context refers to blood relations only. It is important to identify where the woman / birthing person has conceived using a donated egg.
\nThis section allows for information to be recorded about the genetic relations of the fetus e.g. egg and sperm donors.
\nAny family history recorded against the fetus during the pregnancy within the woman / birthing person\u2019s record must handle the context and relate to the subject of the record i.e. the unborn baby.
\nThere will be one \u2018family history\u2019 instance for the woman / birthing person which should be used to record any relevant family/genetic history.
\n \nGroup containing details of the family history identifier, this allows, for example, fetal genetic family history to be recorded where the donor is not the person carrying the fetus
\n ", "concept": [{"type": "item", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "M", "name": "Identifier", "implementationGuidance": "Identifier to link the family history to the subject", "description": "\nIdentifier to link the family history to the subject
\n ", "valueDomain": [{"type": "identifier"}]}, {"type": "item", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "M", "name": "Identifier type", "implementationGuidance": "Identifier type for the family history identifier", "description": "\nIdentifier type for the family history identifier
\n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Fetal order", "implementationGuidance": "Fetal order", "description": "Fetal order", "valueSets": "\nFetal order
\n ", "valueDomain": [{"type": "count"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Relationship to person", "implementationGuidance": "The relationship of the family member with the condition to the person.", "description": "The relationship of the family member with the condition to the person.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for relationship to person", "description": "The coded value for relationship to person", "valueSets": "FHIR value set: Person relationship type
"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text field to be used if no code is available", "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": "Family history", "implementationGuidance": "The record of relevant illness in family relations deemed to be significant to the care or health of the person, including mental illness and suicide, genetic information etc.", "description": "The record of relevant illness in family relations deemed to be significant to the care or health of the person, including mental illness and suicide, genetic information etc.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for family history", "description": "The coded value for family history", "valueSets": "\nFree text
\n ", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Comment", "implementationGuidance": "Any further textual comment.", "description": "Any further textual comment.", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Vaccinations", "implementationGuidance": "\nThis section allows for the recording of all immunisations both administered during pregnancy and those given historically.
\nThe vaccinations recorded must be in line with nationally agreed naming and utilisation conventions.
\nAll discrete data elements associated with any immunisation administered (including travel vaccinations) should be recorded in this section.
\nThis heading allows for retrospective recording any immunisations as reported by the woman / birthing person, including those given abroad.
\n \n\n
This is the vaccinations record entry.
\n\n
There may be 0 to many record entries under a section.
\n\n
Each record entry is made up of a number of elements or data items.
\n ", "informationType": "Event.Record", "concept": [{"type": "group", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "R", "name": "Vaccine product", "implementationGuidance": "The vaccine product administered.", "description": "The vaccine product administered.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for vaccine product.", "description": "The coded value for vaccine product.", "valueSets": "dm+d (SNOMED) Concept ID AMP (preferred) or VMP term for the vaccine product
^999000541000001108 |National Health Service dictionary of medicines and devices actual medicinal product simple reference set (foundation metadata concept)| OR ^999000561000001109 |National Health Service\n dictionary of medicines and devices virtual medicinal product simple reference set (foundation metadata concept)|
"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text field to be used if no code is available", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Manufacturer", "implementationGuidance": "Name of vaccine manufacturer.", "description": "Name of vaccine manufacturer.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value of the manufacturer.", "description": "The coded value of the manufacturer.", "valueSets": "SNOMED CT: - DM+D or GS1"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text field to be used if no code is available", "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": "Vaccine procedure", "implementationGuidance": "The procedure which was used to administer the vaccine.", "description": "The procedure which was used to administer the vaccine.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for vaccine procedure.", "description": "\nSNOMED CT :-
<<127785005 |Administration to produce immunity, either active or passive (procedure)| OR
<<713404003 |Vaccination given (situation)|
"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text field to be used if no code is available", "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": "Batch number", "implementationGuidance": "The batch number of the product.", "description": "The batch number of the product.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for the batch number", "description": "The coded value for the batch number", "valueSets": "FMD code : - Derived from Falsified medicines directive"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text field to be used if no code is available", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Expiry date", "implementationGuidance": "The date on which the vaccine will expire.", "description": "The date on which the vaccine will expire.", "valueSets": "Date/time", "valueDomain": [{"type": "datetime", "property": [{"timeStampPrecision": "YMDHM"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Serialisation code", "implementationGuidance": "A code that separately identifies two identical vaccines (i.e. same product, same batch).", "description": "A code that separately identifies two identical vaccines (i.e. same product, same batch).", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for serialisation code.", "description": "The coded value for serialisation code.", "valueSets": "FMD code : - Derived from Falsified medicines directive"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text field to be used if no code is available", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Body site", "implementationGuidance": "Body site vaccine was administered.", "description": "Body site vaccine was administered.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for body site", "description": "The coded value for body site", "valueSets": "SNOMED CT :
^1127941000000100 |Vaccine body site of administration simple reference set (foundation metadata concept)|
"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text field to be used if no coded text available", "description": "Free text field to be used if no coded text available", "valueSets": "\nFree text
\n ", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Route", "implementationGuidance": "How the vaccine entered the body.", "description": "How the vaccine entered the body.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for vaccination route", "description": "The coded value for vaccination 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", "implementationGuidance": "Free text field to be used if no coded text available", "description": "Free text field to be used if no coded text available", "valueSets": "\nFree text
\n ", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Indication", "implementationGuidance": "The clinical indication or reason for administering the vaccine.", "description": "The clinical indication or reason for administering the vaccine.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for Indication.", "description": "The coded value for Indication.", "valueSets": "SNOMED CT:
^1127601000000107 |Healthcare matters simple reference set (foundation metadata concept)|
"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text field to be used if no code is available", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Dose amount", "implementationGuidance": "Amount of vaccine administered.", "description": "Amount of vaccine administered.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "Amount of vaccine administered.", "description": "Amount of vaccine administered."}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Value", "implementationGuidance": "The amount of vaccine administered", "description": "The amount of vaccine administered", "valueSets": "Free text", "valueDomain": [{"type": "string"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Units of measure", "implementationGuidance": "The units of measure for the dose amount", "description": "The units of measure for the dose amount", "valueSets": "UCUM code", "valueDomain": [{"type": "string", "property": [{"maxLength": "10"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Amount of vaccine administered.", "description": "Amount of vaccine administered.", "valueSets": "Free text", "valueDomain": [{"type": "string", "property": [{"maxLength": "150"}]}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Dose sequence", "implementationGuidance": "Nominal position in a series of vaccines.", "description": "Nominal position in a series of vaccines.", "valueSets": "Numeric value", "valueDomain": [{"type": "decimal", "property": [{"maxInclude": "1"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Outcome status", "implementationGuidance": "Whether the vaccine was administered or not, including the reason why", "description": "Whether the vaccine was administered or not, including the reason why", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Not given flag", "implementationGuidance": "Flag to indicate that the vaccination was NOT given at this time by a healthcare professional", "description": "Flag to indicate that the vaccination was NOT given at this time by a healthcare professional", "valueSets": "Flag: - Yes or No", "valueDomain": [{"type": "boolean", "property": [{"fixed": "3"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Vaccination situation (not given reason)", "implementationGuidance": "The reason why a vaccination was not administered.", "description": "The reason why a vaccination was not administered.", "valueSets": "\nThis section allows for the recording of information related to the maternity episode and includes a start and end date which allows for the opening and closing of the maternity episode.
A Maternity Episode may result in one or more labours and a Labour may result in one or more births.
The \u2018pregnancy identifier\u2019 must be used to tie together data relating to a specific pregnancy. This allows specific contacts and activities carried out (e.g. scans, tests, observations, findings, diagnoses) to be linked back to the intervention for that pregnancy. The \u2018pregnancy identifier\u2019 is used as a national identifier to uniquely\n identify each pregnancy that a woman / birthing person may have. If this identifier is not currently autogenerated then it is suggested that the NHS Number of the woman / birthing person should be used with a locally defined appendage.
", "description": "Identifier used to tie together data relating to a specific pregnancy, allowing specific contacts and activities carried out (e.g. scans, tests, observations, findings, diagnoses) to be linked back to the booking appointment for that pregnancy", "valueDomain": [{"type": "text"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Maternity Episode Start Date", "implementationGuidance": "The start date of the maternity episode", "description": "The start date of the maternity episode", "valueSets": "\nDate and time
\n ", "valueDomain": [{"type": "datetime"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Maternity Episode End Date", "implementationGuidance": "The end date of the maternity episode", "description": "The end date of the maternity episode", "valueSets": "\nDate and time
\n ", "valueDomain": [{"type": "datetime"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Maternity Episode End Reason", "implementationGuidance": "The reason the person's record was closed was discharged from maternity services before giving birth e.g, migration, death, loss to follow up (LTFU), military transfer.", "description": "The reason the person's record was closed was discharged from maternity services before giving birth e.g, migration, death, loss to follow up (LTFU), military transfer.
", "valueSets": "NHS Data Dictionary :- Primary Discharge Reason (Mother Maternity Services)
"}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Booking appointment details", "implementationGuidance": "Information collected during the woman / birthing person's booking appointment.", "description": "Information collected during the woman / birthing person's booking appointment.
", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date of appointment", "implementationGuidance": "The date of the booking appointment.", "description": "The date of the booking appointment.
", "valueSets": "NHS Data Dictionary: - APPOINTMENT DATE (FORMAL ANTENATAL BOOKING)
"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Reason for late booking", "implementationGuidance": "The reason why the person did not have her booking appointment with the maternity service before she was 12 weeks and 6 days into her pregnancy.", "description": "\nThe reason why the person did not have her booking appointment with the maternity service before she was 12 weeks and 6 days into her pregnancy.
\n ", "valueSets": "NHS Data Dictionary :- LATE ANTENATAL BOOKING APPOINTMENT REASON
"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Disability indicator at antenatal booking", "implementationGuidance": "An indication as to whether the woman / birthing person has been diagnosed as disabled or considers themselves to be disabled as reported at the booking appointment.", "description": "An indication as to whether the woman / birthing person has been diagnosed as disabled or considers themselves to be disabled as reported at the booking appointment.
", "valueSets": "NHS Data Dictionary:- DISABILITY INDICATOR (AT ANTENATAL BOOKING)
"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Mental health prediction and detection indicator at antenatal booking", "implementationGuidance": "An indication as to whether the recommended questions for prediction and detection of mental health issues have been asked at the booking appointment.", "description": "An indication as to whether the recommended questions for prediction and detection of mental health issues have been asked at the booking appointment.
", "valueSets": "NHS Data Dictionary: - MENTAL HEALTH PREDICTION AND DETECTION INDICATOR (AT ANTENATAL\n BOOKING)
"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Complex social factors indicator at antenatal booking", "implementationGuidance": "An indication as to whether the woman / birthing person is subject to complex social factors as identified during the booking appointment.", "description": "An indication as to whether the woman / birthing person is subject to complex social factors as identified during the booking appointment.
", "valueSets": "NHS Data Dictionary: - COMPLEX SOCIAL FACTORS INDICATOR (AT ANTENATAL\n BOOKING)
"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Partner employment status indicator at antenatal booking", "implementationGuidance": "An indication of the employment status for the woman / birthing person's spouse or partner as reported during the appointment.", "description": "An indication of the employment status for the woman / birthing person's spouse or partner as reported during the appointment.
", "valueSets": "NHS Data Dictionary: - EMPLOYMENT STATUS (PARTNER AT ANTENATAL BOOKING)
"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Support status indicator at antenatal booking", "implementationGuidance": "An indication of whether the woman / birthing person reports feeling they are supported in pregnancy and looking after the baby, from partner, family, or friends.", "description": "An indication of whether the woman / birthing person reports feeling they are supported in pregnancy and looking after the baby, from partner, family, or friends.
", "valueSets": "NHS Data Dictionary: - SUPPORT STATUS INDICATOR (AT ANTENATAL\n BOOKING)
"}, {"type": "item", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "M", "name": "Parents consanguineous indicator", "implementationGuidance": "Parents consanguineous indicator", "description": "Parents consanguineous indicator", "valueSets": "125678001 | First degree blood relative (person)
699110007 | Second degree blood relative (person)
1269487002\u00a0 | Third degree blood relative (person)
1269486006\u00a0 | Fourth degree blood relative
842009 | Consanguinity (finding)
"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Folic acid supplement status at antenatal booking", "implementationGuidance": "This element should be used to record where the biological mother and biological father are blood relations.
", "description": "The status of whether the woman / birthing person has been taking folic acid supplements.
", "valueSets": "NHS Data Dictionary: - FOLIC ACID SUPPLEMENT STATUS (AT ANTENATAL BOOKING)
"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Seen a dentist in the last 6 months", "implementationGuidance": "Has the birthing person seen a dentist in the last 6 months", "description": "\nHas the birthing person seen a dentist in the last 6 months
\n ", "valueSets": "\nBoolean: yes or no
\n ", "valueDomain": [{"type": "boolean"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Maternal problems in pregnancy", "implementationGuidance": "\u00a0Problems diagnosed as a result of the pregnancy.", "description": "\u00a0Problems diagnosed as a result of the pregnancy.
", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Problem list", "implementationGuidance": "Problem list", "description": "Problem list", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Problem", "implementationGuidance": "A condition which needs addressing and so is important for every professional to know about when seeing the person. \n \n Problems may include diagnoses, symptoms, and social or behavioural issues", "description": "A condition which needs addressing and so is important for every professional to know about when seeing the person.The period covering antenatal, Intrapartum and postnatal phases
", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Maternity episode time period", "implementationGuidance": "The period during which a maternity episode occurs", "description": "The period during which a maternity episode occurs
", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "Coded value for maternity episode time period", "description": "Coded value for maternity episode time period
", "valueSets": "SNOMED CT: 1156672001 | Maternal antenatal period (qualifier value) | 1156682000 | Maternal intrapartum period (qualifier value) | 263844007 | Maternal postnatal period (qualifier value) |
"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text to be used when no code is available", "description": "Free text to be used when no code is available
", "valueDomain": [{"type": "string"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Maternal episode continuity of carer", "implementationGuidance": "Details of maternal episode continuity of carer", "description": "Details of maternal episode continuity of carer
", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional record entry", "implementationGuidance": "This is a health care professional record entry. There may be 0 to many record entries under a section.", "description": "This is a health care professional record entry. There may be 0 to many record entries under a section.
"}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Care Plan", "implementationGuidance": "Details of care plan", "description": "Details of care plan
", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Care and support plan", "implementationGuidance": "This records the decisions reached during conversation between the individual and health and care professional about future plans and also records progress.", "description": "This records the decisions reached during conversation between the individual and health and care professional about future plans and also records progress.", "informationType": "Event.Record"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Birth experience ", "implementationGuidance": "This element contains the woman/birthing person's own words about their own birth experience.", "description": "This element contains the woman/birthing person's own words about their own birth experience.
", "valueSets": "\nFree text
\n ", "valueDomain": [{"type": "text"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Bereavement and loss indicator", "implementationGuidance": "Bereavement and loss indicator", "description": "Bereavement and loss indicator", "valueSets": "Boolean
", "valueDomain": [{"type": "boolean"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Individual requirements", "implementationGuidance": "\nThis section allows for the recording of any of the individual requirements of the woman / birthing person.
\nThis section allows for the recording of individual requirements that need to be met to ensure that the woman / birthing person receives care and support, e.g. interpreter for woman / birthing person, wheelchair access for carer to attend appointments.
\nSpecific disabilities would be included in the \u2019Problem list\u2019 section however the requirements to support the disabilities (e.g., needs wheelchair access, needs large print etc.) would be included in this section.
\nThe data options in this section comply with the NHS England Accessible Information Standard which sets out a specific, consistent approach to identifying, recording, flagging, sharing and meeting the information and communication support needs of patients, service users, carers and parents with a disability, impairment or sensory loss. Further\n information on the Accessible Information Standard can be found here: https://www.england.nhs.uk/about/equality/equality-hub/patient-equalities-programme/equality-frameworks-and-information-standards/accessibleinfo/.
\nA record of reasonable adjustments that must be provided by the service to comply with the Equality Act 2010.
\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": "*", "mro": "R", "name": "Reasonable adjustment record entry", "implementationGuidance": "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", "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", "informationType": "Event.Record", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Reasonable adjustment flag", "implementationGuidance": "\nUnder the Equality Act 2010, organisations have a legal duty to make changes in their approach or provision to ensure that services are as accessible to people with disabilities as they are for everybody else. These changes are called reasonable adjustments.
\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\n across the NHS.
\nSNOMED CT: - 1108111000000107 |Requires reasonable adjustments for health and care access (Equality Act 2010) (finding)|
\nUnder 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": "\nThe reasonable adjustment required e.g. requires specific contact method, requires communication professional.
\n ", "description": "\nThe reasonable adjustment required e.g. requires specific contact method, requires communication professional.
\n \n ", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for reasonable adjustment", "description": "The coded value for reasonable adjustment", "valueSets": "\nRefer to the DAPB4019: Reasonable Adjustment Digital Flag Requirements\n Specification (Amd 77/2020) Document for further detail on the List of Reasonable Adjustment SNOMED codes group by category (including DCB1605).
\n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text field to be used if no code is available", "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", "implementationGuidance": "Further detail about the support required and the consequence of not providing it.", "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": "Impairment", "implementationGuidance": "\nA record of any impairments for the person relating to reasonable adjustments.
\n ", "description": "A record of any impairments for the person relating to reasonable adjustments.", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Impairment record entry", "implementationGuidance": "This is an impairment record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items", "description": "This is an impairment record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items", "informationType": "Event.Record", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Impairment category", "implementationGuidance": "\nThe category of the impairment e.g. Autism, Dementia, Physical disability, Sensory disability - such as sight or hearing, Long-term condition.
\n ", "description": "\nDetails of the persons cognitive impairment.
\n ", "description": "Details of the persons cognitive impairment.", "informationType": "Event.Record", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Cognition", "implementationGuidance": "The cognitive impairment to be considered when communicating with the person, child or their primary carer.", "description": "The cognitive impairment to be considered when communicating with the person, child or their primary carer.", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Mobility", "implementationGuidance": "\nDetails of the person's mobility needs.
\n ", "description": "Details of the person's mobility needs.", "informationType": "Event.Record", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Mobility needs", "implementationGuidance": "\nThe mobility needs of the person that allows movement between two spaces and achieves participation and a degree of independence.
\n ", "description": "The mobility needs of the person that allows movement between two spaces and achieves participation and a degree of independence.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for mobility needs", "description": "The coded value for mobility needs", "valueSets": "\nThis element allows for the recording of any additional individual requirements in communication, cultural, learning or mobility needs; where deemed clinically appropriate to record. For example, a requirement for treatment by female clinicians only.
\n ", "description": "\nThis section should be used to record information about any national screening programmes that the woman / birthing person has taken part in. This includes information about the screening programme's name, status, process, results, and outcomes.
", "description": "Details of the person's participation in national screening programmes.", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "National screening programme record entry", "implementationGuidance": "This is a national screening programme 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.\u00a0", "description": "This is a national screening programme 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.\u00a0", "informationType": "Event.Record", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Screening programme name", "implementationGuidance": "The name of the screening programme.\u00a0", "description": "The name of the screening programme.\u00a0", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for screening programme name.", "description": "The coded value for screening programme name.", "valueSets": "\nThis element allows for the recording of the outcome of screenings, rather than the full results. The full results must be structured in the appropriate section (e.g. \u2018National Screening Programme Results'). It is important to recognise the difference between the outcome of screening and the outcome of a test. The outcome of the screening process maybe\n that they need a test whereas the outcome of a test is positive or negative.
\nThe outcome of the \u2018venous sample performed to screen for sickle cell and thalassemia\u2019 will be recorded from the blood test result. This will be entered by the midwife until systems are integrated.
\nThis section is used to record inactive conditions. Some systems may decide to add start and end dates to relevant past history.
\nThis section allows for the recording of the woman / birthing person\u2019s significant medical, surgical and mental health history.
\nWhere there is no known history, it is recommended that the SNOMED CT code of \u2018no history of\u2019 should be used.
\nMidwifery records are subject to the same reliability provisos as other medical records in other clinical settings. The information recorded by the midwife does not automatically become part of a wider shared record. It is first necessary for a clinician to validate a record, e.g. medical history before subsequent use in another setting/system. As in\n other clinical settings where there is overwriting of a past entry of for example medical history there will be an audit trail of this and associated accountability. It is also noted that research shows that patient provided information is often more accurate than that in existing medical records.
\nWhen using SNOMED CT to record medical history it is important to adhere to the principles set out in the SNOMED CT Technical Implementation Guide provided by SNOMED International. Below is an example of an expression included with explicit attributes/qualifier pairs which allows information to be recorded in a way that takes account of contextual\n information. Local implementation may utilise a local information model to record the dynamic parts of the expression, but should note the SNOMED CT reference model and attributes, as bindings. It is most important to take this into account when sharing historical information without loss of meaning.
\n243796009 |Situation with explicit context (situation)|
\n{
\n246090004 |Associated finding (attribute) = Your history finding code here,
\n408731000 |Temporal context (attribute) = 410513005 |In the past (qualifier value)|
\n}
\n243796009 |Situation with explicit context (situation)|
\n{
\n363589002 |Associated procedure (attribute)| = Your history procedure code here,
\n408731000 |Temporal context (attribute) = 410513005 |In the past (qualifier value)|
\n}
\nGroup containing details of past clinical and social care history
\n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Clinical History record entry", "implementationGuidance": "Information relating to the evolution of each presenting complaint, and the patient's relevant health history.", "description": "Information relating to the evolution of each presenting complaint, and the patient's relevant health history.", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Patient\u2019s reason for referral", "implementationGuidance": "Patient stated reason for referral. This may include any discussions that took place, the level of shared decision making involved, information about patient\u2019s source of advice. This may be expressed on behalf of the patient, e.g. by parent or carer.\u00a0", "description": "Patient stated reason for referral. This may include any discussions that took place, the level of shared decision making involved, information about patient\u2019s source of advice. This may be expressed on behalf of the patient, e.g. by parent or carer.\u00a0", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for patients reason for referral", "description": "The coded value for patients reason for referral", "valueSets": "SNOMED CT :-\u00a0 ^1127581000000103 |Health issues simple reference set| \n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text field to be used if no code is available.", "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": "Primary presenting complaint or issue", "implementationGuidance": "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.", "description": "The health problem or issue experienced by the person resulting in their attendance. This may include disease state, medical condition, response and reactions to therapies. e.g., blackout, dizziness, chest pain, follow up from admission, falls, a specific procedure, investigation or treatment.", "informationType": "Event.Record", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for presenting complaint or issue", "description": "The coded value for presenting complaint or issue", "valueSets": "SNOMED CT : - ^1127581000000103 |Health issues simple reference set| \n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "valueSets": "Free text", "valueDomain": [{"type": "string", "property": [{"maxLength": "150"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "History of each presenting complaint or issue", "implementationGuidance": "History of presenting complaint is associated with the specific presenting complaint", "description": "\nHistory of presenting complaint is associated with the specific presenting complaint
\n ", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Information directly related to the development and characteristics of each presenting complaint (e.g. including travel history). Including if the information is given by the patient or their carer. This textual description may be provided by the referral document or during the consultation", "description": "Information directly related to the development and characteristics of each presenting complaint (e.g. including travel history). Including if the information is given by the patient or their carer. This textual description may be provided by the referral document or during the consultation", "valueSets": "Free text", "valueDomain": [{"type": "text"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Secondary presenting complaint or issue", "implementationGuidance": "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.", "description": "The health problem or issue experienced by the person resulting in their attendance. This may include disease state, medical condition, response and reactions to therapies. e.g., blackout, dizziness, chest pain, follow up from admission, falls, a specific procedure, investigation or treatment.", "informationType": "Event.Record", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for presenting complaint or issue", "description": "The coded value for presenting complaint or issue", "valueSets": "SNOMED CT : - ^1127581000000103 |Health issues simple reference set| \n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "valueSets": "Free text", "valueDomain": [{"type": "string", "property": [{"maxLength": "150"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "History of each presenting complaint or issue", "implementationGuidance": "History of presenting complaint is associated with the specific presenting complaint", "description": "\nHistory of presenting complaint is associated with the specific presenting complaint
\n ", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Information directly related to the development and characteristics of each presenting complaint (e.g. including travel history). Including if the information is given by the patient or their carer. This textual description may be provided by the referral document or during the consultation", "description": "Information directly related to the development and characteristics of each presenting complaint (e.g. including travel history). Including if the information is given by the patient or their carer. This textual description may be provided by the referral document or during the consultation", "valueSets": "Free text", "valueDomain": [{"type": "text"}]}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "History since last contact", "implementationGuidance": "History since last attendance, discharge from hospital, etc. To\u00a0include adherence to treatment plan, where appropriate", "description": "History since last attendance, discharge from hospital, etc. To\u00a0include adherence to treatment plan, where appropriate", "valueSets": "Free text", "valueDomain": [{"type": "text"}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Clinical Review of Systems", "implementationGuidance": "Information gathered on symptoms related to physiological systems.", "description": "Information gathered on symptoms related to physiological systems.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Clinical review of systems", "implementationGuidance": "The clinical review of systems. This is the record of the review of systems as volunteered by the patient or their representative or carer.\u00a0 The record of clinical information gathered in responses to questions to the patient about specific symptoms from various physiological systems, including food intake (increasing/decreasing) weight change, swallowing difficulties etc.\u00a0", "description": "The clinical review of systems. This is the record of the review of systems as volunteered by the patient or their representative or carer.\u00a0 The record of clinical information gathered in responses to questions to the patient about specific symptoms from various physiological systems, including food intake\n (increasing/decreasing) weight change, swallowing difficulties etc.\u00a0", "valueSets": "SNOMED CT: -\u00a0415300000 |Review of systems (procedure)|", "valueDomain": [{"type": "text"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Past history record entry", "implementationGuidance": "\nMedical history is recorded under 'past medical history', 'past surgical history', and 'past mental health history' in coded and free text, and this information is shared both within maternity settings and other care settings outside maternity.
\n ", "description": "Past history record entry", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Past medical history", "implementationGuidance": "\nMedical history should include recording at an appropriate level to reflect the certainty e.g. symptom or problem if unsure of a diagnosis. In the absence of a diagnosis or disorder, symptom or symptoms should be recorded.
\n ", "description": "\nThe record of the person\u2019s significant medical history. Including relevant previous diagnoses, problems and issues, procedures, investigations, specific anaesthesia issues, etc. (will include dental and obstetric history)
A list of the person's relevant past medical history recorded in free text or coded form or Information relating to past medical, surgical\n and mental health history may be provided by the referral document or during the consultation.
The coded value relevant past medical history
\n ", "valueSets": "SNOMED CT : -\u00a0 ^1127581000000103 |Health issues simple reference set| \n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text field to be used if no code is available", "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": "Past surgical history", "implementationGuidance": "The record of the person\u2019s significant surgical history. Including relevant previous diagnoses, problems and issues, procedures, investigations, specific anaesthesia issues, etc. (will include dental and obstetric history)\n\nA list of the person's relevant past surgical history recorded in free text or coded form or Information relating to past surgical history may be provided by the referral document or during the consultation.", "description": "\nThe record of the person\u2019s significant surgical history. Including relevant previous diagnoses, problems and issues, procedures, investigations, specific anaesthesia issues, etc. (will include dental and obstetric history)
A list of the person's relevant past surgical history recorded in free text or coded form or Information relating to past surgical\n history may be provided by the referral document or during the consultation.
The coded value relevant past surgical history
\n ", "valueSets": "SNOMED CT : -\u00a0 ^1127581000000103 |Health issues simple reference set| \n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text field to be used if no code is available", "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": "Past mental health history", "implementationGuidance": "The record of the person\u2019s significant mental health history. Including relevant previous diagnoses, problems and issues, procedures, investigations, specific anaesthesia issues, etc. (will include dental and obstetric history)\n\nA list of the person's relevant past mental health history recorded in free text or coded form or Information relating to past medical, surgical and mental health history may be provided by the referral document or during the consultation.", "description": "\nThe record of the person\u2019s significant mental health history. Including relevant previous diagnoses, problems and issues, procedures, investigations, specific anaesthesia issues, etc. (will include dental and obstetric history)
A list of the person's relevant past mental health history recorded in free text or coded form or Information relating to past\n medical, surgical and mental health history may be provided by the referral document or during the consultation.
The coded value relevant mental health history
\n ", "valueSets": "SNOMED CT : -\u00a0 ^1127581000000103 |Health issues simple reference set| \n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text field to be used if no code is available", "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": "Information and advice given", "implementationGuidance": "\nThis section should be used to record advice given in relation to the pregnancy and other health promotion provided by healthcare professionals during the maternity episode.
\nWhere the woman / birthing person is provided with literature (e.g. pamphlets) there is no need to provide details of the information contained in the literature e.g. simply state that the woman / birthing person was provided with a pamphlet on breast feeding.
\nIn some instances health care professionals may want to communicate the specific information and advice which was given to the woman/ birthing person. It is important that this is concise and is only information which it is pertinent to be aware of.
\nThe oral, written, or multi-media information or advice given to the person, carer, other authorised representative, care professional or other third party. May include advice about actions related to medicines or other ongoing care activities on an \u2018information prescription'. State here if there are concerns about the extent to which the person and/or carer understand\n the information provided about diagnosis, prognosis and treatment.
\n ", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for information and advice given.", "description": "The coded value for information and advice given.", "valueSets": "SNOMED CT."}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text field to be used if no code is available", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date", "implementationGuidance": "The date on which the information and advice was given.", "description": "The date on which the information and advice was given.", "valueSets": "Date and time.", "valueDomain": [{"type": "datetime", "property": [{"timeStampPrecision": "YMDHM"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Investigation results ", "implementationGuidance": "This section should be used to record results for any investigations that have concluded for both the woman/birthing person and the fetus.
Investigations that have been requested, but have not concluded, should be recorded in the Investigations Requested section.
Investigation results
\n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Diagnostic report conclusion", "implementationGuidance": "Concise and clinically contextualized summary conclusion (interpretation/impression) of the diagnostic report.", "description": "\nConcise and clinically contextualized summary conclusion (interpretation/impression) of the diagnostic report.
\n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Diagnostic report group", "implementationGuidance": "Diagnostic report group", "description": "Diagnostic report group", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Investigation results group record entry", "implementationGuidance": "This is a investigation result record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.", "description": "This is a investigation result record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.", "informationType": "Event.Record", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Investigation results record entry", "implementationGuidance": "Investigation test group", "description": "Investigation test group", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Test result identifier", "implementationGuidance": "A unique identifier assigned to this observation.", "description": "\nA unique identifier assigned to this observation.
\n ", "valueDomain": [{"type": "string"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Test result status", "implementationGuidance": "The status of the result value.", "description": "\nThe status of the result value.
\n ", "valueDomain": [{"type": "string"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Performer type", "implementationGuidance": "Who was responsible for asserting the observed value as \"true\".", "description": "\nWho was responsible for asserting the observed value as \"true\".
\n ", "valueDomain": [{"type": "string"}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Investigation name", "implementationGuidance": "Indicates the mechanism used to perform the observation.", "description": "\nIndicates the mechanism used to perform the observation.
\n ", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for investigation", "description": "The coded value for investigation", "valueSets": "\nSNOMED CT ID | Fully specified name (FSN)
\n^ 1853551000000106 | Pathology and laboratory medicine observable entity simple reference set
\n^ 999002881000000100 | Pathology Bounded Code List observables simple reference set
\n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text field to be used if no code is available", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Investigation type", "implementationGuidance": "Indicates the mechanism used to perform the observation.", "description": "\nIndicates the mechanism used to perform the observation.
\n ", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for investigation", "description": "The coded value for investigation", "valueSets": "\nSNOMED CT ID | Fully specified name (FSN)
\n<! 272394005 |Technique (qualifier value|
\n<! 129264002 |Action (qualifier value|
\n<! 386053000 |Evaluation procedure(procedure) |
\nSNOMED CT ID | Fully specified name (FSN)
\n< 363787002 |Observable entity (observable entity)|
\n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text field for detailing the unstructured investigation result (i.e. the textual body of the report).\u00a0", "description": "\nSNOMED CT ID | Fully specified name (FSN)
\n< 363787002 |Observable entity (observable entity)|
\n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Value", "implementationGuidance": "The value of the investigation result.", "description": "The value of the investigation result.", "valueSets": "Numeric", "valueDomain": [{"type": "string", "property": [{"maxLength": "10"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Units of measure", "implementationGuidance": "The units of the investigation result.", "description": "The units of the investigation result.", "valueSets": "UCUM code", "valueDomain": [{"type": "string", "property": [{"maxLength": "10"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Reference ranges", "implementationGuidance": "The reference range for the investigation result.", "description": "The reference range for the investigation result.", "valueSets": "Free text", "valueDomain": [{"type": "string"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Interpretation", "implementationGuidance": "The assessment made based on the result of the investigation e.g high, low.", "description": "\nProvides a reason why the expected value is missing.
\n ", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "Coded value for data absent reason.", "description": "\nCoded value for data absent reason.
\n ", "valueSets": "\nImport all codes from CodeSystem\u00a0DataAbsentReason
\nhttps://simplifier.net/packages/hl7.fhir.r4.core/4.0.1/files/83657
\n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text", "description": "Free text", "valueDomain": [{"type": "string"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Interpretation", "implementationGuidance": "A categorical assessment of an observation value. For example, high, low, normal.", "description": "\nA categorical assessment of an observation value. For example, high, low, normal.
\n ", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "Coded value for interpretation.", "description": "\nCoded value for interpretation.
\n ", "valueSets": "\nImport all codes from CodeSystem\u00a0v3.ObservationInterpretation
\nhttps://simplifier.net/packages/hl7.fhir.r4.core/4.0.1/files/80843
\n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text", "description": "Free text", "valueDomain": [{"type": "string"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Body site", "implementationGuidance": "Indicates the site on the subject's body where the observation was made (i.e. the target site).", "description": "\nIndicates the site on the subject's body where the observation was made (i.e. the target site).
\n ", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "Coded value for body site.", "description": "\nCoded value for body site.
\n ", "valueSets": "\nSNOMED CT ID | Fully specified name (FSN)
\n442083009 (Anatomical or acquired body site (body structure)
\n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text", "description": "Free text", "valueDomain": [{"type": "string"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Investigation method", "implementationGuidance": "Indicates the mechanism used to perform the observation.", "description": "\nIndicates the mechanism used to perform the observation.
\n ", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "Coded value", "description": "Coded value", "valueSets": "\nSNOMED CT ID | Fully specified name (FSN)
\n272394005 (Technique (qualifier value)
\n129264002 (Action (qualifier value)
\n386053000 (Evaluation procedure(procedure)
\n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text", "description": "Free text", "valueDomain": [{"type": "string"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Specimen type", "implementationGuidance": "The specimen that was used when this observation was made.", "description": "\nThe specimen that was used when this observation was made.
\n ", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "Coded value", "description": "Coded value", "valueSets": "\nSNOMED CT ID | Fully specified name (FSN)
\n< 49755003 | Morphologically abnormal structure (morphologic abnormality) |
\n< 105590001 | Substance (substance) |
\n< 123037004 | Body structure (body structure) |
\n< 123038009 | Specimen (specimen) |
\n< 260787004 | Physical object (physical object) |
\n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text", "description": "Free text", "valueDomain": [{"type": "string"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Reference range", "implementationGuidance": "Guidance on how to interpret the value by comparison to a normal or recommended range.", "description": "\nGuidance on how to interpret the value by comparison to a normal or recommended range.
\n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Reference range lower bound", "implementationGuidance": "The value of the low bound of the reference range. The low bound of the reference range endpoint is inclusive of the value (e.g. reference range is >=5 - <=9). If the low bound is omitted, it is assumed to be meaningless (e.g. reference range is <=2.3).", "description": "\nThe value of the low bound of the reference range. The low bound of the reference range endpoint is inclusive of the value (e.g. reference range is >=5 - <=9). If the low bound is omitted, it is assumed to be meaningless (e.g. reference range is <=2.3).
\n ", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for reference range lower bound.\u00a0", "description": "The coded value for reference range lower bound.\u00a0", "valueSets": "SNOMED CT.Codes to indicate the what part of the targeted reference population it applies to. For example, the normal or therapeutic range.
\n ", "valueSets": "\nImport all codes from CodeSystem\u00a0ObservationReferenceRangeMeaningCodes
\nhttps://simplifier.net/packages/hl7.fhir.r4.core/4.0.1/files/79103
\n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Reference range applies to", "implementationGuidance": "Reference range applies to", "description": "Reference range applies to", "valueSets": "\nImport all codes from the following ValueSet(s):
\n\n v3.Race\n
\nThe following codes from system:\u00a0SNOMED_CT
\n\n https://simplifier.net/packages/hl7.fhir.r4.core/4.0.1/files/79631\n
\nSNOMED CT ID | Fully specified name (FSN)
\n248153007 | Male (finding) |
\n248152002 | Female (finding) |
\n77386006 | Pregnancy (finding) |
\n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Reference range age", "implementationGuidance": "The age at which this reference range is applicable. This is a neonatal age (e.g. number of weeks at term) if the meaning says so.", "description": "\nThe age at which this reference range is applicable. This is a neonatal age (e.g. number of weeks at term) if the meaning says so.
\n ", "valueDomain": [{"type": "string"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Reference range text", "implementationGuidance": "Text based reference range in an observation which may be used when a quantitative range is not appropriate for an observation. An example would be a reference value of \"Negative\" or a list or table of \"normals\".", "description": "\nText based reference range in an observation which may be used when a quantitative range is not appropriate for an observation. An example would be a reference value of \"Negative\" or a list or table of \"normals\".
\n ", "valueDomain": [{"type": "string"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Diagnostic report conclusion", "implementationGuidance": "Concise and clinically contextualized summary conclusion (interpretation/impression) of the diagnostic report.", "description": "\nConcise and clinically contextualized summary conclusion (interpretation/impression) of the diagnostic report.
\n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Conclusion", "implementationGuidance": "Conclusion", "description": "Conclusion", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "Coded value", "description": "Coded value", "valueDomain": [{"type": "string"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text", "description": "Free text", "valueDomain": [{"type": "string"}]}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Comment", "implementationGuidance": "Any additional comment or clarification about the structured investigation result.\u00a0", "description": "\nDescribes what was observed. Sometimes this is called the observation \"name\".
\n ", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for investigation", "description": "The coded value for investigation", "valueSets": "\nIndicates the mechanism used to perform the observation.
\n ", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "Coded value", "description": "Coded value", "valueDomain": [{"type": "string"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text", "description": "Free text", "valueDomain": [{"type": "string"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Comment", "implementationGuidance": "Any additional comment or clarification about the structured investigation result.\u00a0", "description": "\nThe 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.
\nNon-technical guidance for medication information has been developed by the PRSB in collaboration with NHS Digital and NHS England and should be referred to alongside the guidance below. See https://theprsb.org/projects-2/digitalmedicationinformation/\n
\nThis section allows for the recording of medication. The purpose of the record is to record medication taken prior to and at conception and current medications (snapshots). The relevant transfer of care models can be used for referral, discharge, and outpatient medication, which would be communicated as part of these transfers of care. This may be as a\n result of the woman / birthing person informing the healthcare professional what medication they are on or have been on in the past.
\nThe section also allows for the recording of medication changes that are made prior to the discharge of the woman / birthing person.
\nThis section is not suitable for use in the dispensing or administration of medication in the maternity setting.
\nAll medications and devices that have been issued to be entered via this Medication item entry. Handles details of continuation / addition / amendment of admission medications.
\n ", "informationType": "Event.Record", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Medication item cluster", "implementationGuidance": "Medication item cluster", "description": "Medication item cluster", "informationType": "Event.Record", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date", "implementationGuidance": "The date on which the medication or medical device was prescribed.", "description": "The date on which the medication or medical device was prescribed.", "valueSets": "Date and time", "valueDomain": [{"type": "datetime", "property": [{"timeStampPrecision": "YMDHM"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Medication prescribed by", "implementationGuidance": "The type of organisation responsible for authorising and issuing the medication e.g. GP", "description": "The type of organisation responsible for authorising and issuing the medication e.g. GPFree text
\n ", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Over the counter medication flag", "implementationGuidance": "Indicates if the medication or device is acquired without a prescription i.e. got by the person over the counter", "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", "implementationGuidance": "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.", "description": "A structural representation of the elements carried by the dose syntax in 'parsable dose strength / timing' i.e. dose strength, dose timing, dose duration and maximum dose.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Dose type", "implementationGuidance": "The kind of rate or dose specified\u00a0", "description": "The kind of rate or dose specified\u00a0", "valueSets": "Calculated or ordered", "valueDomain": [{"type": "boolean"}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Structured dose amount", "implementationGuidance": "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):\u00a0[https://simplifier.net/guide/DoseSyntaxImplementationGuidanceforFHIRR4/Home](https://simplifier.net/guide/DoseSyntaxImplementationGuidanceforFHIRR4/Home \"\")", "description": "\nDose direction duration can be derived from the start and end dates if no other information is available.
\n ", "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):\u00a0 https://simplifier.net/guide/DoseSyntaxImplementationGuidanceforFHIRR4/Home \n ", "valueSets": "Numeric", "valueDomain": [{"type": "quantity"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Dose directions description", "implementationGuidance": "\nThe free text Dose directions description is the form of dosage direction typically used in UK GP Systems.
\n ", "description": "Describes the entire medication dosage and administration directions including dose quantity and medication frequency and optionally duration e.g. \u201c1 tablet at night\" or \u201c2mg at 10pm\u201d.", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Maxdoseperperiod", "implementationGuidance": "The maximum total quantity of a therapeutic substance that may be administered to a subject over the period of time. For example, 1000mg in 24 hours.", "description": "The maximum total quantity of a therapeutic substance that may be administered to a subject over the period of time. For example, 1000mg in 24 hours.", "valueSets": "Numeric", "valueDomain": [{"type": "quantity"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Maxdoseperadministration", "implementationGuidance": "The maximum total quantity of a therapeutic substance that may be administered to a subject per administration.", "description": "The maximum total quantity of a therapeutic substance that may be administered to a subject per administration.", "valueSets": "Numeric", "valueDomain": [{"type": "quantity"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Repeat medication", "implementationGuidance": "Is the medication prescribed to be repeated", "description": "Is the medication prescribed to be repeated", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Number of repeat prescriptions", "implementationGuidance": "The number of repeated prescriptions", "description": "The number of repeated prescriptions", "valueSets": "Numeric", "valueDomain": [{"type": "decimal"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Review date", "implementationGuidance": "Date to review the repeat medication prescribed to the person", "description": "Date to review the repeat medication prescribed to the person", "valueSets": "Date and time", "valueDomain": [{"type": "datetime", "property": [{"timeStampPrecision": "YMD"}]}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Additional instructions", "implementationGuidance": "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.", "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", "implementationGuidance": "Details of the overall course of medication.", "description": "Details of the overall course of medication.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Course status", "implementationGuidance": "The status of this prescription.", "description": "The status of this prescription.", "valueSets": "FHIR value set : - Medication status \n| \n \n \n dm+d:- any code from the VTM, VMP, AMP, VMPP and AMPP concept classes \n | \n
Free text field to be used if no code is available.
\n ", "valueSets": "Free text", "valueDomain": [{"type": "string", "property": [{"maxLength": "150"}]}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Status", "implementationGuidance": "The status of any change made to the medication. MUST CONTAIN STOPPED.", "description": "The status of any change made to the medication. MUST CONTAIN STOPPED.", "valueSets": "FHIR value set: - Medication status \n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Indication", "implementationGuidance": "The clinical indication for any changes in medication status", "description": "The clinical indication for any changes in medication status", "valueSets": "\nA Maternity Episode may result in one or more labours and a Labour may result in one or more births.
\nAs a principle, if there is a difference in an element recorded within this section based around the fetus in the instances of a multiple pregnancy, then these fields should be repeated per fetus.
\nDuration
\n ", "valueDomain": [{"type": "duration"}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Rupture of membranes", "implementationGuidance": "Rupture of membranes", "description": "Rupture of membranes", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Rupture of membranes type", "implementationGuidance": "Rupture of membranes type", "description": "Rupture of membranes type", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "Coded value for rupture of membranes type", "description": "\nCoded value for rupture of membranes type
\n ", "valueSets": "\nSNOMED CT
\n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text", "description": "Free text", "valueSets": "\nFree text
\n ", "valueDomain": [{"type": "text"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date and Time of Rupture of Membranes", "implementationGuidance": "\nIf an exact time is not known for recording the date and time of the rupture of membranes, an estimated time should be used in order for a system to accurately calculate the total duration.
\n ", "description": "\nDate and Time of Rupture of Membranes
\n ", "valueSets": "\nDate and time
\n ", "valueDomain": [{"type": "datetime"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Duration of Rupture of Membranes", "implementationGuidance": "The duration in hours and minutes as derived using the date of rupture versus current date time", "description": "The duration in hours and minutes as derived using the date of rupture versus current date time", "valueSets": "\nDuration in Hour and minutes
\n ", "valueDomain": [{"type": "duration"}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Amniotic fluid appearance finding", "implementationGuidance": "Amniotic fluid appearance finding", "description": "Amniotic fluid appearance finding", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "Coded value for amniotic fluid appearance", "description": "\nCoded value for amniotic fluid appearance
\n ", "valueSets": "\nSNOMED CT
\n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text to be used if no coded value available", "description": "\nFree text to be used if no coded value available
\n ", "valueSets": "\nFree text
\n ", "valueDomain": [{"type": "text"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Total blood loss in labour and birth", "implementationGuidance": "Total blood loss in labour and birth", "description": "Total blood loss in labour and birth", "valueSets": "\nQuantity
\n ", "valueDomain": [{"type": "quantity"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Genital Tract Trauma during labour or birth", "implementationGuidance": "Genital Tract Trauma during labour or birth", "description": "Genital Tract Trauma during labour or birth", "valueSets": "\nFree text
\n ", "valueDomain": [{"type": "text"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Level of maternal postnatal care", "implementationGuidance": "Level of maternal postnatal care", "description": "Level of maternal postnatal care", "valueSets": "\nFree text
\n ", "valueDomain": [{"type": "text"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Induction of labour record entry (Procedure)", "implementationGuidance": "Group containing details of Induction of labour record entry", "description": "\nGroup containing details of Induction of labour record entry
\n ", "informationType": "\n <p>Event.Record</p> \n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Procedure", "implementationGuidance": "The therapeutic or diagnostic procedure performed. Includes both psychological and medical therapies and procedures. Complementary or alternative procedures should be recorded here.", "description": "The therapeutic or diagnostic procedure performed. Includes both psychological and medical therapies and procedures. Complementary or alternative procedures should be recorded here.
"}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Medication item cluster", "implementationGuidance": "Medication item cluster", "description": "Medication item cluster", "informationType": "Event.Record"}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Cervical Priming", "implementationGuidance": "The method used for undertaking cervical priming", "description": "The method used for undertaking cervical priming
", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Procedure", "implementationGuidance": "The therapeutic or diagnostic procedure performed. Includes both psychological and medical therapies and procedures. Complementary or alternative procedures should be recorded here.", "description": "The therapeutic or diagnostic procedure performed. Includes both psychological and medical therapies and procedures. Complementary or alternative procedures should be recorded here.
"}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Medication item cluster", "implementationGuidance": "Medication item cluster", "description": "Medication item cluster", "informationType": "Event.Record"}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Medical devices entry", "implementationGuidance": "Medical devices", "description": "Medical devices", "informationType": "Record"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Timestamp for artificial rupture of membranes", "implementationGuidance": "The date and time of artificial rupture of membranes", "description": "\nThe date and time of artificial rupture of membranes
\n ", "valueSets": "\nDate and time
\n ", "valueDomain": [{"type": "datetime"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Labour 1st stage record entry", "implementationGuidance": "Labour 1st stage record entry", "description": "Labour 1st stage record entry", "informationType": "\n <p>Event.Record</p> \n ", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date and time of Established Labour", "implementationGuidance": "The Date/time when established labour is confirmed - regular painful contractions and progressive cervical dilatation", "description": "The Date/time when established labour is confirmed - regular painful contractions and progressive cervical dilatation", "valueSets": "\nDate and time
\n ", "valueDomain": [{"type": "datetime"}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Location of 1st stage of labour", "implementationGuidance": "Location of 1st stage of labour", "description": "Location of 1st stage of labour", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "Coded value for location of 1st stage of labour", "description": "\nCoded value for location of 1st stage of labour
\n ", "valueSets": "NHS Data dictionary : - Organisation data service code
"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text for use if no coded value available", "description": "\nFree text for use if no coded value available
\n ", "valueSets": "\nFree text
\n ", "valueDomain": [{"type": "text"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Birth place type for 1st stage of labour", "implementationGuidance": "Birth place type for 1st stage of labour", "description": "Birth place type for 1st stage of labour", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "Coded value of Birth place type for 1st stage of labour", "description": "\nCoded value of Birth place type for 1st stage of labour
\n ", "valueSets": "NHS Data Dictionary :- ORGANISATION SITE IDENTIFIER (OF ACTUAL PLACE OF DELIVERY)
"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text if no coded value available", "description": "\nFree text if no coded value available
\n ", "valueSets": "\nFree text
\n ", "valueDomain": [{"type": "text"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Birth place type comment", "implementationGuidance": "Birth place type comment", "description": "Birth place type comment", "valueSets": "\nFree text
\n ", "valueDomain": [{"type": "text"}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Labour Onset details", "implementationGuidance": "The method by which the process of labour began, or delivery by caesarean section occurred.", "description": "\nThe method by which the process of labour began, or delivery by caesarean section occurred.
\n ", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The List of SNOMED codes for labour onset is available on the PRSB's website.
", "description": "\nCoded value for labour onset
\n ", "valueSets": "\nSNOMED CT
\n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text for labour onset details if no code available", "description": "\nFree text for labour onset details if no code available
\n ", "valueSets": "\nFree text
\n ", "valueDomain": [{"type": "text"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date and time Fully Dilated", "implementationGuidance": "The date and time that the woman is deemed to be fully dilated", "description": "The date and time that the woman is deemed to be fully dilated", "valueSets": "\nDate and time
\n ", "valueDomain": [{"type": "datetime"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Duration of 1st Stage", "implementationGuidance": "A derived field based on the time of established labour to the time of full dilation", "description": "A derived field based on the time of established labour to the time of full dilation", "valueSets": "\nDuration
\n ", "valueDomain": [{"type": "duration"}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Pain relief in 1st stage of labour", "implementationGuidance": "Type of pain relief used during 1st stage of labour", "description": "Type of pain relief used during 1st stage of labour
", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Analgesia", "implementationGuidance": "Details of analgesia given", "description": "Details of analgesia given
", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Medication item entry", "implementationGuidance": "All medications and devices that have been issued to be entered via this Medication item entry. Handles details of over-the-counter medication flag/ continuation / addition / amendment of admission medications.", "description": "\nAll medications and devices that have been issued to be entered via this Medication item entry. Handles details of over-the-counter medication flag/ continuation / addition / amendment of admission medications.
\n \n ", "informationType": "Event.Record"}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Anaesthesia", "implementationGuidance": "Details of anaesthesia given", "description": "Details of anaesthesia given
", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Medication item entry", "implementationGuidance": "All medications and devices that have been issued to be entered via this Medication item entry. Handles details of over-the-counter medication flag/ continuation / addition / amendment of admission medications.", "description": "\nAll medications and devices that have been issued to be entered via this Medication item entry. Handles details of over-the-counter medication flag/ continuation / addition / amendment of admission medications.
\n \n ", "informationType": "Event.Record"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Type of fetal monitoring in labour", "implementationGuidance": "Type of fetal monitoring used during 1st stage of labour, including intermittant auscultation, continuous CTG", "description": "Type of fetal monitoring used during 1st stage of labour, including intermittant auscultation, continuous CTG
", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "Coded value for type of fetal monitoring in labour", "description": "Coded value for type of fetal monitoring in labour
"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text field to be used when no code is available", "description": "Free text field to be used when no code is available
", "valueDomain": [{"type": "string"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Labour 2nd stage record entry", "implementationGuidance": "Labour 2nd stage record entry", "description": "Labour 2nd stage record entry", "informationType": "\n <p>Event.Record</p> \n ", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Onset of 2nd Stage of Labour", "implementationGuidance": "The date and time that the second stage of labour was deemed to start", "description": "The date and time that the second stage of labour was deemed to start", "valueSets": "\nDate and time
\n ", "valueDomain": [{"type": "datetime"}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Location of 2nd stage of labour", "implementationGuidance": "Location of 2nd stage of labour", "description": "\nLocation of 2nd stage of labour
\n ", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "Coded value for location of 2nd stage of labour", "description": "\nCoded value for location of 2nd stage of labour
\n ", "valueSets": "NHS Data dictionary : - Organisation data service code
"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text for use if no coded value available", "description": "\nFree text for use if no coded value available
\n ", "valueSets": "\nFree text
\n ", "valueDomain": [{"type": "text"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Birth place type for 2nd stage of labour", "implementationGuidance": "Birth place type for 2nd stage of labour", "description": "\nBirth place type for 2nd stage of labour
\n ", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "Coded value of Birth place type for 2nd stage of labour", "description": "\nCoded value of Birth place type for 2nd stage of labour
\n ", "valueSets": "NHS Data Dictionary :- ORGANISATION SITE IDENTIFIER (OF ACTUAL PLACE OF DELIVERY)
"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text if no coded value available", "description": "\nFree text if no coded value available
\n ", "valueSets": "\nFree text
\n ", "valueDomain": [{"type": "text"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Birth place type comment", "implementationGuidance": "Birth place type comment", "description": "Birth place type comment", "valueSets": "\nFree text
\n ", "valueDomain": [{"type": "text"}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Pain relief in 2nd stage of labour", "implementationGuidance": "Type of pain relief used during 2nd stage of labour", "description": "Type of pain relief used during 2nd stage of labour
", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Analgesia", "implementationGuidance": "Details of analgesia given", "description": "Details of analgesia given
", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Medication item entry", "implementationGuidance": "All medications and devices that have been issued to be entered via this Medication item entry. Handles details of over-the-counter medication flag/ continuation / addition / amendment of admission medications.", "description": "\nAll medications and devices that have been issued to be entered via this Medication item entry. Handles details of over-the-counter medication flag/ continuation / addition / amendment of admission medications.
\n \n ", "informationType": "Event.Record"}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Anaesthesia", "implementationGuidance": "Details of anaesthesia given", "description": "Details of anaesthesia given
", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Medication item entry", "implementationGuidance": "All medications and devices that have been issued to be entered via this Medication item entry. Handles details of over-the-counter medication flag/ continuation / addition / amendment of admission medications.", "description": "\nAll medications and devices that have been issued to be entered via this Medication item entry. Handles details of over-the-counter medication flag/ continuation / addition / amendment of admission medications.
\n \n ", "informationType": "Event.Record"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Type of fetal monitoring in labour", "implementationGuidance": "Type of fetal monitoring used during 2nd stage of labour, including intermittent auscultation, continuous CTG", "description": "Type of fetal monitoring used during 2nd stage of labour, including intermittent auscultation, continuous CTG
", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "Coded value for Type of fetal monitoring in labour", "description": "Coded value for Type of fetal monitoring in labour
"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text to be used when no code is available", "description": "Free text to be used when no code is available
", "valueDomain": [{"type": "string"}]}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date and time pushing commenced", "implementationGuidance": "The date and time that pushing commenced", "description": "The date and time that pushing commenced", "valueSets": "\nDate and time
\n ", "valueDomain": [{"type": "datetime"}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Labour 3rd stage record entry", "implementationGuidance": "Labour 3rd stage record entry", "description": "Labour 3rd stage record entry", "informationType": "\n <p>Event.record</p> \n ", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Onset of 3rd stage of labour", "implementationGuidance": "Date and time of Onset of 3rd stage of labour", "description": "\nDate and time of Onset of 3rd stage of labour
\n ", "valueSets": "\nDate and time
\n ", "valueDomain": [{"type": "datetime"}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Optimal cord clamping", "implementationGuidance": "Optimal cord clamping", "description": "Optimal cord clamping", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Optimal Cord Clamping Duration", "implementationGuidance": "Optimal Cord Clamping Duration", "description": "Optimal Cord Clamping Duration", "valueDomain": [{"type": "string"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Optimal Cord Clamping Details", "implementationGuidance": "Optimal Cord Clamping Details", "description": "Optimal Cord Clamping Details", "valueDomain": [{"type": "text"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Reason optimal cord clamping not done", "implementationGuidance": "\nThe element Reason Optimal Cord Clamping not done\u2019 may be used to record precluded by clinical condition of mother / birthing person and precluded by clinical condition of baby.
\n ", "description": "\nDetails of why the cord clamping was not optimal
\n ", "valueDomain": [{"type": "text"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Placenta delivery record entry", "implementationGuidance": "Each attempt of the placenta delivery should be recorded and not just the last attempt used in delivering the placenta.
", "description": "Placenta delivery record entry", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Procedure", "implementationGuidance": "Placenta delivery Procedure", "description": "\nPlacenta delivery Procedure
\n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Placenta Delivery Method", "implementationGuidance": "The method by which the placenta was removed through physiological, active or manual means.", "description": "The method by which the placenta was removed through physiological, active or manual means.
", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "Coded value for the placenta delivery method", "description": "\nCoded value for the placenta delivery method
\n ", "valueSets": "\nSNOMED CT
\n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text for use if coded value not available", "description": "\nFree text for use if coded value not available
\n ", "valueSets": "\nFree text
\n ", "valueDomain": [{"type": "text"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Medication used", "implementationGuidance": "Medication used during placenta removal", "description": "\nMedication used during placenta removal
\n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Medication item cluster", "implementationGuidance": "Medication item cluster", "description": "Medication item cluster", "informationType": "Event.Record"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Examination of placenta and membranes ", "implementationGuidance": "Examination of placenta and membranes", "description": "\nExamination of placenta and membranes
\n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Examination findings", "implementationGuidance": "Examination findings", "description": "Examination findings"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Umbilical Cord Number of Vessels", "implementationGuidance": "The number of umbilical cord vessels", "description": "The number of umbilical cord vessels", "valueSets": "\nUCUM
\n ", "valueDomain": [{"type": "quantity"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Stem cell collection details", "implementationGuidance": "Stem cell collection details", "description": "Stem cell collection details", "valueSets": "\nFree text
\n ", "valueDomain": [{"type": "text"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Placenta destination", "implementationGuidance": "The destination of the placenta including disposal, given to patient or third party, referral for histopathological examination etc", "description": "\nThe destination of the placenta including disposal, given to patient or third party, referral for histopathological examination etc
\n ", "valueSets": "\nFree text
\n ", "valueDomain": [{"type": "text"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Pain Relief in 3rd stage of labour", "implementationGuidance": "Type of pain relief used during 3rd stage of labour", "description": "Type of pain relief used during 3rd stage of labour
", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Analgesia", "implementationGuidance": "Details of analgesia given", "description": "Details of analgesia given
", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Medication item entry", "implementationGuidance": "All medications and devices that have been issued to be entered via this Medication item entry. Handles details of over-the-counter medication flag/ continuation / addition / amendment of admission medications.", "description": "\nAll medications and devices that have been issued to be entered via this Medication item entry. Handles details of over-the-counter medication flag/ continuation / addition / amendment of admission medications.
\n \n ", "informationType": "Event.Record"}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Anaesthesia", "implementationGuidance": "Details of anaesthesia given", "description": "Details of anaesthesia given
", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Medication item entry", "implementationGuidance": "All medications and devices that have been issued to be entered via this Medication item entry. Handles details of over-the-counter medication flag/ continuation / addition / amendment of admission medications.", "description": "\nAll medications and devices that have been issued to be entered via this Medication item entry. Handles details of over-the-counter medication flag/ continuation / addition / amendment of admission medications.
\n \n ", "informationType": "Event.Record"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Pain Relief in 3rd stage of labour", "implementationGuidance": "Type of pain relief used during 3rd stage of labour", "description": "\nType of pain relief used during 3rd stage of labour
\n ", "valueSets": "\nFree text: Analgesia or Anaesthesia
\n ", "valueDomain": [{"type": "text"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "End of 3rd stage of labour", "implementationGuidance": "Date and time of end of 3rd stage of labour", "description": "\nDate and time of end of 3rd stage of labour
\n ", "valueSets": "\nDate and time
\n ", "valueDomain": [{"type": "datetime"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Participation in research", "implementationGuidance": "\nThis heading section should be used to flag participation in clinical trials or other research initiatives.
\nThis should include the name of the research trial that the woman / birthing person is actively engaged in and, if available, the URL with further details of the trial.
\n\u2022 It should be possible to restrict access to the care and support plan in most cases based on the individual\u2019s consent preferences. However, a data controller may choose to release all or part of the record for legitimate reasons, for example when a person using services is unable to give consent.
\n\u2022 It should be possible to add attachments or hyperlinks in care and support plans to provide guidance, learning materials, explanatory notes, etc. The date/time of the hyperlink/addition should be included.
\n\u2022 It should be possible to add comments to the plan and to sections in the plan, for example. to identify progress towards a goal (which should have a formal mechanism associated for capturing information). It should also be possible to comment on actions undertaken or suggest changes to actions. Note that adding comments to a plan is not the same as having a\n dialogue with others involved in the care and support planning process. Separate functionality, e.g. secure messaging would be required for this.
", "description": "This records the decisions reached during conversation between the individual and health and care professional about future plans and also records progress.", "informationType": "Event.Record", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Strengths", "implementationGuidance": "Any strengths and assets the person has (i.e. things a person is good at or enjoys doing) relating to their goals and hopes about their health and well-being For example, \u2018able to participate in leisure activities\u2019 such as a sport in order to improve health and wellbeing.
", "description": "Any strengths and assets the person has relating to their goals and hopes about their health and well-being.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value ", "implementationGuidance": "The coded value associated with the person's strengths.\u00a0 Could be derived from the assessment of the person e.g.\u00a0300738008 |Able to participate in leisure activities (finding)|", "description": "The coded value associated with the person's strengths.\u00a0 Could be derived from the assessment of the person e.g.\u00a0300738008 |Able to participate in leisure activities (finding)|Free text for the target if not coded version exists
\n ", "valueDomain": [{"type": "text"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Units of measure", "implementationGuidance": "The units of measure for the target.", "description": "The units of measure for the target.", "valueSets": "UCUM code", "valueDomain": [{"type": "string", "property": [{"maxLength": "10"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Ordinal", "implementationGuidance": "The ordinal for the target e.g. mild, moderate, severe.", "description": "The ordinal for the target e.g. mild, moderate, severe.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for the ordinal target.", "description": "The coded value for the ordinal target.", "valueSets": "SNOMED CT."}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text field to be used if no code is available", "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", "implementationGuidance": "Any additional comment or clarification about the target.", "description": "Any additional comment or clarification about the target.", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Needs, concerns or problems", "implementationGuidance": "\u2022 Needs are defined as health or care deficits identified by the person with their carer(s) or professionals and are the motivations/indications for healthcare activities. Examples of needs could be (e.g.) \u2018to dress myself\u2019; \u2018to better understand what my various medications are for\u2019; \u2018to reduce pain in my knees\u2019.
\n\u2022 Concerns are gathered information to support continuity of care for a person. Concerns can include biological, psychological or social concerns. They may include things the person or carer is concerned about. For example, a person\u2019s concern may be \u2018the quality of social housing\u2019; a professional\u2019s concern could be \u2018high blood pressure\u2019
\n\u2022 Problems are defined as: A condition that needs addressing and is important for every professional to know about when seeing a person. Problems may include diagnoses (e.g. COPD; diabetes), symptoms (e.g. joint pain; breathlessness), disabilities (e.g. sensory impairments; amputations), health, social and behavioural issues. Problems recorded here may link to\n the problem list held in a shared care record or GP system for a person using services.
\n\u2022 Goals and hopes are defined as: The overall goals, hopes, aims or targets that the person has. Including anything that the person wants to achieve that relates to their future health and wellbeing. Each goal may include a description of why it is important to the person. Goals may also be ranked in order of importance or priority to the person. For example,\n \u2018weight loss\u2019; smoking cessation\u2019; \u2018reducing alcohol intake\u2019; \u2018increased sleep\u2019. \u2018Goals\u2019 tends to be historically a more medically-used term, whereas \u2018hopes\u2019 is used more widely in social care settings.
\n\u2022 It should be possible to include tables (e.g. weekly schedule), diagrams or images (e.g. to illustrate how a person has made progress towards a goal) as well as video and audio clips (i.e. as a communication tool for individuals with complex accessibility requirements).
\n\u2022 It should be possible to prioritise goals, indicating the importance of each goal to the person (e.g. a scale 1 to 10). \u2022 Each action may also have an associated additional indicator showing how confident the person is to carry it out (e.g. a scale from 1 to 10).
\n\u2022 The care and support plan should be structured in a way that supports digital information exchange, with separate sections for strengths, needs and problems which can be linked to specific goals. \u2022 Of particular importance is the link between needs in a care plan and related goals. Each goal must link to specific needs, as well as any actions associated with\n it. Goals may also have related outcomes.
\n\u2022 The sections associated with goals and actions that are the focus of specific care professionals should be interoperable with the care plan that professional uses for their day to day work. Updates to the care and support plan section may include:
\n\u2022 Add, edit or archive strengths, needs, concerns or problems. If a strength/need/concern becomes more or less important, then goals may need to be changed, as will associated actions.
\n\u2022 Add, edit or archive goals. When a goal is archived it should be possible to also archive the actions associated with it. If the actions are still valid it should be possible to attach them to another goal.
\n\u2022 Add, edit or archive actions. Once an action has been completed (i.e. status updated to indicate it has been completed), it should be possible to archive it from the care and support plan. It should be removed from the current active view of the plan, but available to view in previous versions of the plan.
\n\u2022 Recording outcomes related to goals. Once a goal has been achieved, it should be possible to archive it from the care and support plan, so that it is removed from the view of the current plan, but available to view in previous versions of the care and support plan.
", "description": "Details of the person needs, concerns or problemsAlignment to the workforce dataset NHS Occupation codes primarily is advised. Where no code is available, free text may be used.
\nNational Workforce Data Set (NWD) NHS Occupation codes are found here: -\u00a0https://digital.nhs.uk/data-and-information/data-collections-and-data-sets/data-sets/national-workforce-data-set-nwd-and-nhs-occupation-codes. To access the list of roles, download the 'NWD dataset specification' using the link on the page.
\nThe Staff Groups and Job Roles are listed in the \u2018NWD Class & Codes Appendix\u2019 tab of the attached NWD Dataset from row 640. The 'Staff Group' and 'Job Role' segments are contained in one field named 'Job' which work together e.g. Staff Group = Nursing & Midwifery Registered and Job Role = Staff Nurse.
\n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Team", "implementationGuidance": "The name of the team.", "description": "The name of the team.", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "35"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "implementationGuidance": "Contact details of the professional (e.g. telephone number, email address etc.).", "description": "Contact details of the professional (e.g. telephone number, email address etc.).", "valueSets": "Free text", "valueDomain": [{"type": "string", "property": [{"maxLength": "35"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Where", "implementationGuidance": "Where the care and support plan action is expected to be undertaken", "description": "\nWhere the care and support plan action is expected to be undertaken
\n ", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "Coded value for the care and support plan action location", "description": "\nCoded value for the care and support plan action location
\n ", "valueSets": "\nCodeset will be project specific and therefore should be defined in implementation guidance
\n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text for use if no coded value available", "description": "\nFree text for use if no coded value available
\n ", "valueSets": "\nFree text
\n ", "valueDomain": [{"type": "text"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "When", "implementationGuidance": "Planned date, time, or interval, as relevant", "description": "Planned date, time, or interval, as relevant", "valueSets": "\nDate and time, or other representation of a time period
\n ", "valueDomain": [{"type": "string"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Suggested strategies", "implementationGuidance": "Suggested strategies for potential problems.", "description": "Suggested strategies for potential problems.", "valueSets": "Free text.", "valueDomain": [{"type": "text"}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Status", "implementationGuidance": "The status of the action or activity e.g. in progress, done, refused", "description": "The status of the action or activity e.g. in progress, done, refused", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for the person's activity status", "description": "The coded value for the person's activity status", "valueSets": "\n\u2022 Agreement and understanding of the plan with the person (or representative) should be recorded. If agreement or understanding cannot be obtained, the reason for this should be documented.
\n\u2022 Where a person has been unable to agree, due to, for example, lacking mental capacity, actions should be undertaken to maximise capacity and the plan should demonstrate how a person\u2019s rights will be promoted. If a person is unable to consent, a mental capacity assessment should be attempted, and if there is no legal representative a best interest decision\n made.
", "description": "Information about whether the care plan has been understood and agreed with the person.
", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person's ability to agree care plan", "implementationGuidance": "Information about whether the person is able to agree to the care plan.", "description": "Information about whether the person is able to agree to the care plan.
", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "Coded value for the person's ability to agree to the care plan.", "description": "Coded value for the person's ability to agree to the care plan.
", "valueSets": "SNOMED CT: 714411005 Able to agree with care plan (finding) | 714830003 Unable to agree with care plan (finding)
"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text to be used if coded value not available.", "description": "Free text to be used if coded value not available.
", "valueDomain": [{"type": "text"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Legitimate representative details", "implementationGuidance": "Details of the person's legitimate representative, if they have one.", "description": "Details of the person's legitimate representative, if they have one.
", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Legitimate representative appointed status", "implementationGuidance": "Details of whether the person has been appointed a legitimate representative.", "description": "Details of whether the person has been appointed a legitimate representative.
", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for the legitimate representative appointed status.", "description": "The coded value for the legitimate representative appointed status.
", "valueSets": "SNOMED CT
"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text to be used if coded value not available.", "description": "Free text to be used if coded value not available.
", "valueDomain": [{"type": "text"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Legitimate representative name", "implementationGuidance": "The name of the person's legitimate representative.", "description": "The name of the person's legitimate representative.
", "valueDomain": [{"type": "text"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Legitimate representative role", "implementationGuidance": "The role of the person's legitimate representative.", "description": "The role of the person's legitimate representative.
", "valueDomain": [{"type": "text"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Care plan understanding status group", "implementationGuidance": "Details of whether the care plan has been understood by the person or their legitimate representative.", "description": "Details of whether the care plan has been understood by the person or their legitimate representative.
", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Care plan understood status", "implementationGuidance": "The status of whether the care plan has been understood.", "description": "The status of whether the care plan has been understood.
", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for the care plan understood status.", "description": "The coded value for the care plan understood status.
", "valueSets": "SNOMED CT
"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text to be used if coded value not available.", "description": "Free text to be used if coded value not available.
", "valueDomain": [{"type": "text"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Reason for lack of understanding", "implementationGuidance": "The reason for lack of understanding the care plan, if the care plan has not been understood.", "description": "The reason for lack of understanding the care plan, if the care plan has not been understood.
", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for the reason for lack of understanding of the care plan.", "description": "The coded value for the reason for lack of understanding of the care plan.
", "valueSets": "SNOMED CT
"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text to be used if coded value not available.", "description": "Free text to be used if coded value not available.
", "valueDomain": [{"type": "text"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Care plan agreement status group", "implementationGuidance": "Details of whether the care plan has been agree with the person or their legitimate representative.", "description": "Details of whether the care plan has been agree with the person or their legitimate representative.
", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Care plan agreement status", "implementationGuidance": "The status of whether the care plan has been agreed to.", "description": "The status of whether the care plan has been agreed to.
", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for the care plan agreement status.", "description": "The coded value for the care plan agreement status.
", "valueSets": "SNOMED CT: 714831004 Does agree with care plan (finding) | 707165003 Does not agree with care plan (finding)
"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text to be used if coded value not available.", "description": "Free text to be used if coded value not available.
", "valueDomain": [{"type": "text"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Reason for lack of agreement", "implementationGuidance": "The reason for lack of agreement to the care plan, if the care plan has not been agreed to.", "description": "The reason for lack of agreement to the care plan, if the care plan has not been agreed to.
", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for the reason for the lack of agreement.", "description": "The coded value for the reason for the lack of agreement.
"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text to be used if coded value not available.", "description": "Free text to be used if coded value not available.
", "valueDomain": [{"type": "text"}]}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Care funding source", "implementationGuidance": "In health and social care there may be different sources of funding (e.g. personal budget/personal health budgets) to meet the aims and goals of the person. The \u2018Care Funding Source\u2019 section should only detail the source of the funding so as to support easy resolution where a question about funding arises. The information should not include\n the details of the funding, which will be held in separate documents.
", "description": "A reference to the funding source and any conditions or limitations associated.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The organisation code of the care funding source", "description": "The organisation code of the care funding source", "valueSets": "NHS data dictionary : - organisation data service \n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text ", "implementationGuidance": "Any further information for the person's care funding source e.g. self funded", "description": "Any further information for the person's care funding source e.g. self funded", "valueSets": "Free text\u00a0", "valueDomain": [{"type": "text"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date this plan was last updated", "implementationGuidance": "This information should be automatically retrievable from the system.
", "description": "This is a record of the date that this care and support plan was last updated.", "valueSets": "Date and time", "valueDomain": [{"type": "datetime", "property": [{"timeStampPrecision": "YMDHM"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Other care planning documents", "implementationGuidance": "Reference other care planning documents, including the type, location and date. \n \n This may include condition-specific plans, advance care plans, end of life care plan, etc.", "description": "Reference other care planning documents, including the type, location and date.Alignment to the workforce dataset NHS Occupation codes primarily is advised. Where no code is available, free text may be used.
\nNational Workforce Data Set (NWD) NHS Occupation codes are found here: -\u00a0https://digital.nhs.uk/data-and-information/data-collections-and-data-sets/data-sets/national-workforce-data-set-nwd-and-nhs-occupation-codes. To access the list of roles, download the 'NWD dataset specification' using the link on the page.
\nThe Staff Groups and Job Roles are listed in the \u2018NWD Class & Codes Appendix\u2019 tab of the attached NWD Dataset from row 640. The 'Staff Group' and 'Job Role' segments are contained in one field named 'Job' which work together e.g. Staff Group = Nursing & Midwifery Registered and Job Role = Staff Nurse.
\n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "implementationGuidance": "Contact details of the professional (e.g. telephone number, email address etc.).", "description": "Contact details of the professional (e.g. telephone number, email address etc.).", "valueSets": "Free text", "valueDomain": [{"type": "string", "property": [{"maxLength": "35"}]}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Plan and requested actions", "implementationGuidance": "This is the treatment plan for the treating team or clinician and any actions requested.
This is not a care plan it is a plan for specific actions to be carried out as a result of an encounter.
This plan should make clear who is expected to take responsibility for actions following an encounter, for example the person receiving care or their carer; the GP or another heath care professional.
The section allows for the recording of planned investigations, procedures and treatment for the person\u2019s identified conditions and priorities.
Status of the action
\n ", "valueDomain": [{"type": "text"}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Location", "implementationGuidance": "The location where the action should happen.", "description": "\nThe location where the action should happen.
\n ", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for location.", "description": "The coded value for location.", "valueSets": "NHS Data dictionary : - Organisation data service code \n ", "valueDomain": [{"type": "string", "property": [{"minLength": "3", "maxLength": "5"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text field to be used if no code is available", "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": "Strategies", "implementationGuidance": "Including planned investigations, procedures and treatment for a person's identified conditions and priorities. For each action the following should be identified:outcome expectations, including the person\u2019s expectations. A record of the planned and requested actions. May be structured (table), with actions, names, dates, status, location, strategies.", "description": "Including planned investigations, procedures and treatment for a person's identified conditions and priorities. For each action the following should be identified:outcome expectations, including the person\u2019s expectations. A record of the planned and requested actions. May be structured (table), with\n actions, names, dates, status, location, strategies.", "valueSets": "Free text", "valueDomain": [{"type": "text"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Actions for person or their carer", "implementationGuidance": "For each action the following should be identified:outcome expectations, including person\u2019s expectations. A record of the planned and requested actions. May be structured (table), with actions, names, dates, status, location, strategies.", "description": "\nFor each action the following should be identified:outcome expectations, including person\u2019s expectations. A record of the planned and requested actions. May be structured (table), with actions, names, dates, status, location, strategies.
\n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Action entry details", "implementationGuidance": "Action entry details", "description": "Action entry details", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "implementationGuidance": "The relation to the person e.g. father, cousin etc", "description": "The relation to the person e.g. father, cousin etc
", "valueDomain": [{"type": "string"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date", "implementationGuidance": "The date of action for professional recorded.", "description": "\nThe date of action for professional recorded.
\n ", "valueDomain": [{"type": "string"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Status", "implementationGuidance": "Status of the action", "description": "\nStatus of the action
\n ", "valueDomain": [{"type": "text"}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Location", "implementationGuidance": "The location where the action should happen.", "description": "\nThe location where the action should happen.
\n ", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for location.", "description": "The coded value for location.", "valueSets": "NHS Data dictionary : - Organisation data service code \n ", "valueDomain": [{"type": "string", "property": [{"minLength": "3", "maxLength": "5"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text field to be used if no code is available", "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": "Strategies", "implementationGuidance": "Including planned investigations, procedures and treatment for a person's identified conditions and priorities. For each action the following should be identified:outcome expectations, including the person\u2019s expectations. A record of the planned and requested actions. May be structured (table), with actions, names, dates, status, location, strategies.", "description": "Including planned investigations, procedures and treatment for a person's identified conditions and priorities. For each action the following should be identified:outcome expectations, including the person\u2019s expectations. A record of the planned and requested actions. May be structured (table), with\n actions, names, dates, status, location, strategies.", "valueSets": "Free text", "valueDomain": [{"type": "text"}]}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Agreed with the person or their legitimate representative", "implementationGuidance": "Indicates whether the person or their legitimate representative has agreed the entire plan or individual aspects of treatment, expected outcomes, risks and alternative treatments. A record of the agreement of the decisions made.", "description": "Indicates whether the person or their legitimate representative has agreed the entire plan or individual aspects of treatment, expected outcomes, risks and alternative treatments. A record of the agreement of the decisions made.", "valueSets": "Free text", "valueDomain": [{"type": "text"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Outcome of plan and requested actions", "implementationGuidance": "The details of the outcome of the plan and requested actions.", "description": "The details of the outcome of the plan and requested actions.", "valueSets": "Free text.", "valueDomain": [{"type": "text"}]}]}]}, {"version": "V1.0", "type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Procedure", "implementationGuidance": "All procedures undertaken during the maternity episode should be included during the maternity episode, including:
a. diagnostic as well as therapeutic procedures
b. procedures carried out on different days during the hospital stay.
Adverse reactions to anaesthesia should be recorded in the \u2018allergies and adverse reactions\u2019 section, rather than the \u2018procedures and therapies\u2019 section, but should be displayed in both headings under the 'specific \u2018anaesthesia issues\u2019 element. The anaesthesia issues recorded in this section could include for example, \u201cshort neck, difficult to intubate\u201d and the actual intubation grade.
This is an example list of procedures that may take place in the maternity setting and may be recorded under this heading: Amniocentesis; Sampling of chorionic villus (CVS); External cephalic version; Artificial rupture of membranes for augmentation of labour; Induction of Labour - Prostaglandin; Induction of Labour - Oxytocin; Artificial rupture of membranes; Episiotomy; C-Section, forcep assist; C-Section, low transverse.
This section may be used to record chorionicity and amniocity where a person has a multiple pregnancy.
Whilst hospitals use the OPCS Classification of Interventions and Procedures codes for procedures, these cannot be used by GP practices, so should not be included in discharge summaries. The text associated with the code should be communicated and matched to the relevant SNOMED CT code, rather than the OPCS code.
The details of any procedures performed.
", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Procedure record entry", "implementationGuidance": "This is a procedure record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.", "description": "This is a procedure record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Procedure", "implementationGuidance": "Whilst hospitals use the OPCS Classification of Interventions and Procedures codes for procedures, these cannot be used by GP practices, so should not be included in discharge summaries. The text associated with the code should be communicated and matched to the relevant SNOMED CT code, rather than the OPCS code.
", "description": "The therapeutic or diagnostic procedure performed. Includes both psychological and medical therapies and procedures. Complementary or alternative procedures should be recorded here.
", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded entry", "implementationGuidance": "The procedure code", "description": "The procedure code
", "valueSets": "SNOMED CT : - <71388002 |Procedure| OR <129125009 |Procedure with explicit context|
"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text field to be used if no code is available", "description": "Free text field to be used if no code is available
", "valueSets": "Free text
", "valueDomain": [{"type": "string"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Reason for procedure", "implementationGuidance": "The reason why the procedure was undertaken", "description": "The reason why the procedure was undertaken
", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded entry", "implementationGuidance": "Coded value for the reason for procedure", "description": "Coded value for the reason for procedure
", "valueSets": "SNOMED CT
"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text field to be used if no code is available", "description": "Free text field to be used if no code is available
", "valueSets": "Free text
", "valueDomain": [{"type": "string"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Part of (parent procedure)", "implementationGuidance": "Details of the parent procedure that this procedure is part of", "description": "Details of the parent procedure that this procedure is part of
", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for the part of (parent procedue)", "description": "The coded value for the part of (parent procedue)
", "valueSets": "SNOMED CT : - <71388002 |Procedure| OR <129125009 |Procedure with explicit context|
"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text field to be used when no code is available", "description": "Free text field to be used when no code is available
", "valueSets": "Free text
", "valueDomain": [{"type": "string"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Performer", "implementationGuidance": "Details of the health professional performing the procedure", "description": "Details of the health professional performing the procedure
", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Health care professional", "implementationGuidance": "Details of health care professional", "description": "Details of health care professional
", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional record entry", "implementationGuidance": "This is a health care professional record entry. There may be 0 to many record entries under a section.", "description": "This is a health care professional record entry. There may be 0 to many record entries under a section.
"}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Not performed reason", "implementationGuidance": "Not performed reason for the procedure", "description": "Not performed reason for the procedure
"}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Not performed reason", "implementationGuidance": "Not performed reason for the procedure", "description": "Not performed reason for the procedure
", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for the not performed reason", "description": "The coded value for the not performed reason
", "valueSets": "https://www.hl7.org/fhir/R4/valueset-procedure-not-performed-reason.html
"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text field when coded value available", "description": "Free text field when coded value available
", "valueSets": "Free text
", "valueDomain": [{"type": "string"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Anatomical site", "implementationGuidance": "The anatomical site at which the procedure is", "description": "The anatomical site at which the procedure is
", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for anatomical site", "description": "The coded value for anatomical site
", "valueSets": "SNOMED CT :- <123037004 |Body structure (body structure)|
"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text field to be used when no code is available", "description": "Free text field to be used when no code is available
", "valueSets": "Free text
", "valueDomain": [{"type": "string"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Laterality", "implementationGuidance": "The laterality of the procedure", "description": "The laterality of the procedure
", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for the laterality", "description": "The coded value for the laterality
", "valueSets": "SNOMED CT:- <182353008 |Side (qualifier value)|
"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text field to be used if no code is available", "description": "Free text field to be used if no code is available
", "valueSets": "Free text
", "valueDomain": [{"type": "string"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Outcome", "implementationGuidance": "Outcome of the procedure", "description": "Outcome of the procedure
", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value of the outcome", "description": "The coded value of the outcome
", "valueSets": "SNOMED CT
"}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Diagnostic report", "implementationGuidance": "Diagnostic report from the procedure", "description": "Diagnostic report from the procedure
", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Documents (including correspondence, audio and images)", "implementationGuidance": "Details about documents related to the person.", "description": "Details about documents related to the person."}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Complications related to procedure", "implementationGuidance": "Details of any intra-operative complications encountered during the procedure, arising during the person\u2019s stay in the recovery unit or directly attributable to the procedure.", "description": "Details of any intra-operative complications encountered during the procedure, arising during the person\u2019s stay in the recovery unit or directly attributable to the procedure.
", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for complications related to procedure", "description": "The coded value for complications related to procedure
", "valueSets": "SNOMED CT : - <404684003 |Clinical finding (finding)|
"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text field to be used when no code is available", "description": "Free text field to be used when no code is available
", "valueSets": "Free text
", "valueDomain": [{"type": "string"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Follow up", "implementationGuidance": "Follow up from the procedure", "description": "Follow up from the procedure
", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for follow up", "description": "The coded value for follow up
", "valueSets": "https://www.hl7.org/fhir/R4/valueset-procedure-followup.html
"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text field to be used when no code is available", "description": "Free text field to be used when no code is available
", "valueSets": "Free text
", "valueDomain": [{"type": "string"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Comments / Clinical notes", "implementationGuidance": "Comments / clinical notes relating to the procedure", "description": "Comments / clinical notes relating to the procedure
", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Comments", "implementationGuidance": "Any further textual comment to clarify such as statement that information is partial or incomplete. Also indicate the outcome of the procedure.", "description": "Any further textual comment to clarify such as statement that information is partial or incomplete. Also indicate the outcome of the procedure.
", "valueSets": "Free text
", "valueDomain": [{"type": "string"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Medication used", "implementationGuidance": "Medication used during the procedure", "description": "Medication used during the procedure
", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Medication item cluster", "implementationGuidance": "Medication item cluster", "description": "Medication item cluster", "informationType": "Event.Record"}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Substance used", "implementationGuidance": "Substance used during the procedure", "description": "Substance used during the procedure
", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Medication item cluster", "implementationGuidance": "Medication item cluster", "description": "Medication item cluster", "informationType": "Event.Record"}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Device used", "implementationGuidance": "Device used during procedure", "description": "Device used during procedure
", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Medical devices entry", "implementationGuidance": "Medical devices", "description": "Medical devices", "informationType": "Record"}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Specific anesthesia issues", "implementationGuidance": "Details of any adverse reaction to any anaesthetic agents including local anaesthesia. Problematic intubation, transfusion reaction, etc.", "description": "Details of any adverse reaction to any anaesthetic agents including local anaesthesia. Problematic intubation, transfusion reaction, etc.
", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for specific anaesthesia issues", "description": "The coded value for specific anaesthesia issues
", "valueSets": "SNOMED CT
"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text field to be used if no code is available", "description": "Free text field to be used if no code is available
", "valueSets": "Free text
", "valueDomain": [{"type": "string"}]}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Therapies", "implementationGuidance": "The details of any procedures performed. Includes both psychological and medical therapies and procedures (e.g. cognitive behaviour therapy, hip replacement)", "description": "The details of any procedures performed. Includes both psychological and medical therapies and procedures (e.g. cognitive behaviour therapy, hip replacement)", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Procedure record entry", "implementationGuidance": "This is a procedure record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.", "description": "This is a procedure record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.", "informationType": "Event.Record", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Procedure", "implementationGuidance": "\nWhilst hospitals use the OPCS Classification of Interventions and Procedures codes for procedures, these cannot be used by GP practices, so should not be included in discharge summaries. The text associated with the code should be communicated and matched to the relevant SNOMED CT code, rather than the OPCS code.
\n ", "description": "The therapeutic or diagnostic procedure performed. Includes both psychological and medical therapies and procedures (e.g. cognitive behaviour therapy, or follow-up interventions as a result of physical health checks). Complementary or alternative procedures and therapies should be recorded here.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The procedure code.", "description": "The procedure code.", "valueSets": "SNOMED CT :
<71388002 |Procedure (procedure)|
"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text field to be used if no code is available", "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": "Reason for procedure", "implementationGuidance": "Reason for procedure", "description": "Reason for procedure", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "Coded value for the reason for procedure", "description": "\nCoded value for the reason for procedure
\n ", "valueSets": "\nSNOMED CT
\n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text if no coded value available", "description": "\nFree text if no coded value available
\n ", "valueDomain": [{"type": "string"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Part of (parent procedure)", "implementationGuidance": "Details of the parent procedure that this procedure is part of", "description": "\nDetails of the parent procedure that this procedure is part of
\n ", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "Coded value for the parent procedure", "description": "\nCoded value for the parent procedure
\n ", "valueSets": "\nSNOMED CT : -\u00a0<71388002 |Procedure|\u00a0OR\u00a0<129125009 |Procedure with explicit context|
\n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text for use if no coded value available", "description": "\nFree text for use if no coded value available
\n ", "valueSets": "\nFree text
\n ", "valueDomain": [{"type": "text"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Not performed reason", "implementationGuidance": "Not performed reason for the procedure", "description": "\nNot performed reason for the procedure
\n ", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "Coded value for the reason that the procedure was not performed", "description": "\nCoded value for the reason that the procedure was not performed
\n ", "valueSets": "\nhttps://www.hl7.org/fhir/R4/valueset-procedure-not-performed-reason.html
\n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text for use if no coded value available", "description": "\nFree text for use if no coded value available
\n "}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Anatomical site", "implementationGuidance": "The body site of the procedure", "description": "The body site of the procedure", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value of the anatomical site.", "description": "The coded value of the anatomical site.", "valueSets": "SNOMED CT :
<123037004 |Body structure (body structure)|
"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text field to be used if no code is available", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Laterality", "implementationGuidance": "Laterality of the procedure", "description": "Laterality of the procedure", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for laterality.", "description": "The coded value for laterality.", "valueSets": "SNOMED CT:
^999000821000000100 |Laterality simple reference set (foundation metadata concept)|
"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text field to be used if no code is available", "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": "Outcome", "implementationGuidance": "Outcome of the procedure", "description": "\nOutcome of the procedure
\n ", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "Coded value", "description": "Coded value", "valueSets": "\nCodeset to be defined
\n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text to be used is coded value is not available", "description": "\nFree text to be used is coded value is not available
\n ", "valueSets": "\nfree text
\n ", "valueDomain": [{"type": "text"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Diagnostic report", "implementationGuidance": "Diagnostic report from the procedure", "description": "\nDiagnostic report from the procedure
\n ", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "Coded value for diagnostic report from procedure", "description": "\nCoded value for diagnostic report from procedure
\n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text for use if no coded value available", "description": "\nFree text for use if no coded value available
\n ", "valueDomain": [{"type": "text"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Complications related to procedure", "implementationGuidance": "Details of any intra-operative complications encountered during the procedure, arising during the person\u2019s stay in the recovery unit or directly attributable to the procedure.", "description": "Details of any intra-operative complications encountered during the procedure, arising during the person\u2019s stay in the recovery unit or directly attributable to the procedure.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for complications relating to procedure.", "description": "The coded value for complications relating to procedure.", "valueSets": "SNOMED CT :
^1127581000000103 |Health issues simple reference set (foundation metadata concept)|
"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text field to be used if no code is available", "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": "Follow up", "implementationGuidance": "Follow up from the procedure", "description": "\nFollow up from the procedure
\n ", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "Coded value for follow up from the procedure", "description": "\nCoded value for follow up from the procedure
\n ", "valueSets": "\nhttps://www.hl7.org/fhir/R4/valueset-procedure-followup.html
\n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text for use if coded value not available", "description": "\nFree text for use if coded value not available
\n ", "valueSets": "\nFree text
\n ", "valueDomain": [{"type": "text"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Comments / clinical notes", "implementationGuidance": "Comments / clinical notes relating to the procedure", "description": "\nComments / clinical notes relating to the procedure
\n ", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Comment", "implementationGuidance": "Any further textual comment to clarify such as statement that information is partial or incomplete. Also indicate the outcome of the procedure.", "description": "Any further textual comment to clarify such as statement that information is partial or incomplete. Also indicate the outcome of the procedure.", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Medication used", "implementationGuidance": "Medication used during the procedure", "description": "\nMedication used during the procedure
\n ", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "Coded value for medication used", "description": "\nCoded value for medication used
\n ", "valueSets": "\nSNOMED CT
\n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text if no coded value available", "description": "\nFree text if no coded value available
\n ", "valueDomain": [{"type": "text"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Substance used", "implementationGuidance": "Substance used during the procedure", "description": "\nSubstance used during the procedure
\n ", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "Coded value for substance used during procedure", "description": "\nCoded value for substance used during procedure
\n ", "valueSets": "\nSNOMED CT
\n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text for use if no coded value available", "description": "\nFree text for use if no coded value available
\n ", "valueDomain": [{"type": "text"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Device used", "implementationGuidance": "Device used during procedure", "description": "\nDevice used during procedure
\n ", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "Coded value for device used during procedure", "description": "\nCoded value for device used during procedure
\n ", "valueSets": "\nSNOMED CT
\n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text for use if no coded value available", "description": "\nFree text for use if no coded value available
\n ", "valueSets": "\nFree text
\n ", "valueDomain": [{"type": "text"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Specific anaesthesia issues", "implementationGuidance": "Details of any adverse reaction to any anaesthetic agents including local anaesthesia. Problematic intubation, transfusion reaction, etc.", "description": "\nDetails of any adverse reaction to any anaesthetic agents including local anaesthesia. Problematic intubation, transfusion reaction, etc.
\n ", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for specific anaesthesia issues.", "description": "\nThe coded value for specific anaesthesia issues.
\n ", "valueSets": "SNOMED CT"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text field to be used if no code is available", "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": "Contraception record entry", "implementationGuidance": "Record entry relating to the person's use of contraception.", "description": "\nRecord entry relating to the person's use of contraception.
\n ", "informationType": "\n <p>Event.Record</p> \n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contraception type", "implementationGuidance": "The type of contraception used.\u00a0", "description": "\nThe type of contraception used.\u00a0
\n ", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for contraception type.", "description": "The coded value for contraception type.", "valueSets": "SNOMED CT
<<13197004 |Uses contraception (finding)|
"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text field to be used if no code is available.", "description": "Free text field to be used if no code is available.", "valueSets": "Free text.", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contraception start date", "implementationGuidance": "The date on which the contraception method was first used by the person.", "description": "The date on which the contraception method was first used by the person.", "valueSets": "\nDate and time
\n ", "valueDomain": [{"type": "date", "property": [{"timeStampPrecision": "YMD"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contraception end date", "implementationGuidance": "The end date of the contraception method used.", "description": "The end date of the contraception method used.", "valueSets": "\nDate and time
\n ", "valueDomain": [{"type": "date", "property": [{"timeStampPrecision": "YMD"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contraception review date", "implementationGuidance": "The date for which the person's contraception needs to be reviewed.", "description": "\nThe date for which the person's contraception needs to be reviewed.
\n ", "valueSets": "\nDate and time
\n ", "valueDomain": [{"type": "date", "property": [{"timeStampPrecision": "YMD"}]}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Clinical Summary", "implementationGuidance": "This is the section to record day-to-day/case notes.
This section is designed to be used to allow the healthcare professional to record a narrative summary (clinical notes) of an encounter. This may include interpretation of findings and results, opinion and specific action(s). Planned actions should be recorded\n under the \u2018Plan and Requested Actions\u2019 section.
The relevant treatments and interventions which the person received during the inpatient stay. Include psychological therapies. All medications should be recorded under the medications section.
\n ", "valueSets": "Free text", "valueDomain": [{"type": "text"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Clinical narrative", "implementationGuidance": "A description detailing a person's reason for attendance, results from the diagnostic and treatment process.", "description": "\nA description detailing a person's reason for attendance, results from the diagnostic and treatment process.
\n ", "valueSets": "Free text", "valueDomain": [{"type": "text"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Clinical history", "implementationGuidance": "Information relating to the evolution of each presenting complaint, and the person's relevant health history.", "description": "\nInformation relating to the evolution of each presenting complaint, and the person's relevant health history.
\n ", "valueDomain": [{"type": "text"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "National Screening Programme Results", "implementationGuidance": "This section records the results of relevant National Screening Programmes relating to maternity. It allows for a National Screening Programme Result to be linked to specific Investigation Results or Examination Findings, allowing for more detailed results to be recorded compared to the National Screening Programmes Section.
", "description": "National Screening Programme Results", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "NHS Sickle Cell and Thalassaemia (SCT) Screening Programme results record entry", "implementationGuidance": "NHS Sickle Cell and Thalassaemia (SCT) Screening Programme results record entry", "description": "NHS Sickle Cell and Thalassaemia (SCT) Screening Programme results record entry", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Sickle cell disease (SCD)", "implementationGuidance": "Sickle cell disease (SCD) investigation result", "description": "\nSickle cell disease (SCD) investigation result
\n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Investigation results ", "implementationGuidance": "Investigation results", "description": "\nInvestigation results
\n "}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Thalassaemia", "implementationGuidance": "Thalassaemia investigation result", "description": "\nThalassaemia investigation result
\n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Investigation results ", "implementationGuidance": "Investigation results", "description": "\nInvestigation results
\n "}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "NHS Infectious Diseases in Pregnancy Screening (IDPS) Programme results record entry", "implementationGuidance": "NHS Infectious Diseases in Pregnancy Screening (IDPS) Programme results record entry", "description": "NHS Infectious Diseases in Pregnancy Screening (IDPS) Programme results record entry", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "HIV", "implementationGuidance": "HIV test investigation result", "description": "\nHIV test investigation result
\n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Investigation results ", "implementationGuidance": "Investigation results", "description": "\nInvestigation results
\n "}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Investigation results ", "implementationGuidance": "Investigation results", "description": "\nInvestigation results
\n "}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Hepatitis B", "implementationGuidance": "Hepatitis B investigation result", "description": "\nHepatitis B investigation result
\n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Investigation results ", "implementationGuidance": "Investigation results", "description": "\nInvestigation results
\n "}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Syphilis", "implementationGuidance": "Syphilis investigation result", "description": "\nSyphilis investigation result
\n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Investigation results ", "implementationGuidance": "Investigation results", "description": "\nInvestigation results
\n "}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "NHS Newborn Bloodspot Screening Programme test results record entry", "implementationGuidance": "NHS Newborn Bloodspot Screening Programme test results record entry", "description": "NHS Newborn Bloodspot Screening Programme test results record entry", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Phenylketonuria (PKU)", "implementationGuidance": "Phenylketonuria (PKU) investigation result", "description": "\nPhenylketonuria (PKU) investigation result
\n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Investigation results ", "implementationGuidance": "Investigation results", "description": "\nInvestigation results
\n "}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Medium-chain acyl-CoA dehydrogenase deficiency (MCADD)", "implementationGuidance": "Medium-chain acyl-CoA dehydrogenase deficiency (MCADD) investigation result", "description": "\nMedium-chain acyl-CoA dehydrogenase deficiency (MCADD) investigation result
\n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Investigation results ", "implementationGuidance": "Investigation results", "description": "\nInvestigation results
\n "}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Maple syrup urine disease (MSUD)", "implementationGuidance": "Maple syrup urine disease (MSUD) investigation result", "description": "\nMaple syrup urine disease (MSUD) investigation result
\n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Investigation results ", "implementationGuidance": "Investigation results", "description": "\nInvestigation results
\n "}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Isovaleric acidaemia (IVA)", "implementationGuidance": "Isovaleric acidaemia (IVA) investigation result", "description": "\nIsovaleric acidaemia (IVA) investigation result
\n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Investigation results ", "implementationGuidance": "Investigation results", "description": "\nInvestigation results
\n "}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Glutaric aciduria type 1 (GA1)", "implementationGuidance": "Glutaric aciduria type 1 (GA1) investigation result", "description": "\nGlutaric aciduria type 1 (GA1) investigation result
\n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Investigation results ", "implementationGuidance": "Investigation results", "description": "\nInvestigation results
\n "}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Homocystinuria (pyridoxine unresponsive) (HCU)", "implementationGuidance": "Homocystinuria (pyridoxine unresponsive) (HCU) investigation result", "description": "\nHomocystinuria (pyridoxine unresponsive) (HCU) investigation result
\n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Investigation results ", "implementationGuidance": "Investigation results", "description": "\nInvestigation results
\n "}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Congenital hypothyroidism (CHT)", "implementationGuidance": "Congenital hypothyroidism (CHT) investigation result", "description": "\nCongenital hypothyroidism (CHT) investigation result
\n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Investigation results ", "implementationGuidance": "Investigation results", "description": "\nInvestigation results
\n "}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional contacts", "implementationGuidance": "The section allows for the display or recording of healthcare professional contacts.
", "description": "The details of the person\u2019s professional contacts.", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Professional contacts record entry", "implementationGuidance": "This is a professional contacts record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.", "description": "This is a professional contacts record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.", "informationType": "Record", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier type", "implementationGuidance": "The type of professional identifier. For example, General Medical Council (GMC); Nursing and Midwifery Council\u00a0(NMC) numbers.", "description": "\nThe type of professional identifier. For example, General Medical Council (GMC); Nursing and Midwifery Council\u00a0(NMC) numbers.
\n ", "valueSets": "\nNationally or internationally maintained code system(s) (see implementation guidance).
\n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professional identifier", "implementationGuidance": "Professional identifier for the professional completing the record e.g. General Medical Council (GMC), Nursing Medical Council (NMC) number etc, or the personal identifier used by the local organisation.", "description": "\nProfessional identifier for the professional completing the record e.g. General Medical Council (GMC), Nursing Medical Council (NMC) number etc, or the personal identifier used by the local organisation.
\n ", "valueSets": "\nFree text
\n ", "valueDomain": [{"type": "string"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "implementationGuidance": "The name of the professional with responsibility for the care of the person.", "description": "The name of the professional with responsibility for the care of the person.", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "70"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "implementationGuidance": "The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc.", "description": "\nThe role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker etc.
\n ", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for role.", "description": "\nThe coded value for role.
\n ", "valueSets": "\nNationally or internationally maintained code system(s). E.g. HL7 FHIR Practitioner/Role; SNOMED; National workforce dataset; NHS Occupation codes. See implementation guidance.
\n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text field to be used if no code is available.", "description": "\nFree text field to be used if no code is available.
\n ", "valueSets": "\nFree text
\n ", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "implementationGuidance": "The grade of the professional.", "description": "The grade of the professional.", "valueSets": "Free text", "valueDomain": [{"type": "string"}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Specialty", "implementationGuidance": "The specialty of the professional e.g. physiotherapy, oncology, mental health, etc.", "description": "\nThe specialty of the professional e.g. physiotherapy, oncology, mental health, etc.
\n ", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded Value", "implementationGuidance": "The coded value for specialty.", "description": "\nThe coded value for specialty.
\n ", "valueSets": "\nNationally or internationally mandated code system(s) (see implementation guidance).
\n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text field to be used if no code is available.", "description": "\nFree text field to be used if no code is available.
\n ", "valueSets": "\nThe local team that the care professional works in.
", "valueDomain": [{"type": "string"}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Professional contact responsibility type", "implementationGuidance": "The professional contact responsibility types for the person e.g. Named professional, Maternity continuity of carer, Key worker", "description": "\nThe professional contact responsibility types for the person e.g. Named professional, Maternity continuity of carer, Key worker
\n ", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "Coded value", "description": "Coded value", "valueDomain": [{"type": "string"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text", "description": "Free text", "valueDomain": [{"type": "string"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Start date", "implementationGuidance": "The start date of the professional relationship with the person.", "description": "The start date of the professional relationship with the person.", "valueSets": "Date and time", "valueDomain": [{"type": "datetime", "property": [{"timeStampPrecision": "YMDHM"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "End date", "implementationGuidance": "The end date of the professional relationship with the person.", "description": "The end date of the professional relationship with the person.", "valueSets": "Date and time", "valueDomain": [{"type": "datetime", "property": [{"timeStampPrecision": "YMDHM"}]}]}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Referral details", "implementationGuidance": "This section is designed to be used to indicate that a referral has been made. It is not the referral itself.
This is an example list of \u2018referrals to\u2019 organisations that may take place in the maternity setting and may be recorded under this heading: Referral to dental service; Referral to diabetes service; Referral to\n dermatology service; Referral to physiotherapy service; Referral for vulnerable adult investigation; Referral to psychology service; Referral to haematology service; Referral to safeguarding team (for example FGM, Domestic Abuse); Referral to social services (e.g. CAF Form commenced).
The \u2018referrer details\u2019 should be copied from the referral or transfer of care where possible.
", "description": "The details of the referrer that is making the referral or the transfer.Alignment to the workforce dataset NHS Occupation codes primarily is advised. Where no code is available, free text may be used.
\nNational Workforce Data Set (NWD) NHS Occupation codes are found here: -\u00a0https://digital.nhs.uk/data-and-information/data-collections-and-data-sets/data-sets/national-workforce-data-set-nwd-and-nhs-occupation-codes. To access the list of roles, download the 'NWD dataset specification' using the link on the page.
\nThe Staff Groups and Job Roles are listed in the \u2018NWD Class & Codes Appendix\u2019 tab of the attached NWD Dataset from row 640. The 'Staff Group' and 'Job Role' segments are contained in one field named 'Job' which work together e.g. Staff Group = Nursing & Midwifery Registered and Job Role = Staff Nurse.
\n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "implementationGuidance": "The grade of the referrer.", "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", "implementationGuidance": "The team or department of the referrer.", "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", "implementationGuidance": "The specialty of the referrer.", "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", "implementationGuidance": "The service of the referrer.", "description": "The service of the referrer.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for service", "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", "implementationGuidance": "Free text field to be used if no code is available", "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", "implementationGuidance": "The organisation of the referrer.", "description": "The organisation of the referrer.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for organisation code", "description": "The coded value for organisation code", "valueSets": "\nNHS 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", "implementationGuidance": "Free text field to be used if no code is available", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Referral type", "implementationGuidance": "An indication of the type of referral (e.g. 'Hospital Discharge Notification to Social Care', 'GP Referral', etc.)", "description": "An indication of the type of referral (e.g. 'Hospital Discharge Notification to Social Care', 'GP Referral', etc.)", "valueSets": "\nFree text
\n ", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Referred by (emergency care)", "implementationGuidance": "The details of where the person was referred to emergency care from.", "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) | \nWhether a woman / birthing person attended a smoking cessation referral appointment can be recorded under the \u2018smoking\u2019 \u2018comment\u2019 section of the record.
Instigate an opt-out referral for all women who have an elevated CO level (4ppm or above), who identify themselves as smokers or have quit in the last 2 weeks for treatment by a trained tobacco dependence treatment adviser (TDA) within an in-house tobacco dependence treatment service.
Alignment to the workforce dataset NHS Occupation codes primarily is advised. Where no code is available, free text may be used.
\nNational Workforce Data Set (NWD) NHS Occupation codes are found here: -\u00a0https://digital.nhs.uk/data-and-information/data-collections-and-data-sets/data-sets/national-workforce-data-set-nwd-and-nhs-occupation-codes. To access the list of roles, download the 'NWD dataset specification' using the link on the page.
\nThe Staff Groups and Job Roles are listed in the \u2018NWD Class & Codes Appendix\u2019 tab of the attached NWD Dataset from row 640. The 'Staff Group' and 'Job Role' segments are contained in one field named 'Job' which work together e.g. Staff Group = Nursing & Midwifery Registered and Job Role = Staff Nurse.
\n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Grade", "implementationGuidance": "The grade of the person where the referral is sent to.", "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", "implementationGuidance": "The team or department of the person where the referral is being sent to", "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", "implementationGuidance": "The specialty the referral is being sent to e.g. physiotherapy, oncology, mental health etc", "description": "The specialty the referral is being sent to e.g. physiotherapy, oncology, mental health etc", "valueSets": "\nThis section is where any concerns, risks or issues in relation to safeguarding are recorded in relation to the woman / birthing person.
The \u2018safeguarding' section \u00a0may potentially contain sensitive information. Therefore, sufficient local role-based access controls should be in place to ensure this information is only shared with those care professionals where there is a need to do so.
\nThere may be situations where it not advisable to share information in this heading with the woman / birthing person to whom it relates. Appropriate policies and technical solutions must be in place for these situations.
\nIndicates whether or not there are safeguarding issues associated with the patient.
", "valueSets": "SNOMED CT
<1010196001 | Safeguarding concern (finding) |
", "valueDomain": [{"type": "boolean"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Safeguarding concerns date", "implementationGuidance": "The date the safeguarding concerns were identified.", "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", "implementationGuidance": "The date safeguarding concerns ended.", "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 concern", "implementationGuidance": "Identified safeguarding concerns.", "description": "Identified safeguarding concerns.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for safeguarding concern.", "description": "The coded value for safeguarding concern.
", "valueSets": "SNOMED CT :
^999002381000000108 |Safeguarding issues simple reference set (foundation metadata concept)|
"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text field to be used if no code is available.", "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": "Safeguarding concern detail", "implementationGuidance": "Safeguarding concern detail", "description": "\nSafeguarding concern detail
\n ", "valueDomain": [{"type": "text"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Comment", "implementationGuidance": "Further details on safeguarding concerns.", "description": "Further details on safeguarding concerns.", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Looked after child", "implementationGuidance": "Details of the looked after child.", "description": "\nThe coded value for local authority.
", "valueSets": "\nFree 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": "Child protection plan", "implementationGuidance": "Details of the child protection plan.", "description": "Details of the child protection plan.
", "informationType": "Record", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Child protection plan start date", "implementationGuidance": "The start date of the child protection plan.", "description": "The start date of the child protection plan.
", "valueSets": "Date and time", "valueDomain": [{"type": "datetime", "property": [{"timeStampPrecision": "YMDHM"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Child protection plan end date", "implementationGuidance": "The end date of the child protection plan.", "description": "The end date of the child protection plan.
", "valueSets": "Date and time", "valueDomain": [{"type": "datetime", "property": [{"timeStampPrecision": "YMDHM"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Local authority", "implementationGuidance": "The named local authority.", "description": "The named local authority.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for local authority.", "description": "The coded value for local authority.
", "valueSets": "\nFree 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": "Unborn child protection plan", "implementationGuidance": "Details of the unborn child protection plan.", "description": "Details of the unborn child protection plan.", "informationType": "Record", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Unborn child protection plan start date", "implementationGuidance": "Start date of the unborn child protection plan.", "description": "Start date of the unborn child protection plan.", "valueSets": "Date and time", "valueDomain": [{"type": "datetime", "property": [{"timeStampPrecision": "YMDHM"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Unborn child protection plan end date", "implementationGuidance": "End date of the unborn child protection plan.", "description": "End date of the unborn child protection plan.", "valueSets": "Date and time", "valueDomain": [{"type": "datetime", "property": [{"timeStampPrecision": "YMDHM"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Local authority", "implementationGuidance": "The named local authority.", "description": "The named local authority.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for local authority.", "description": "The coded value for local authority.
", "valueSets": "\nFree 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": "Risks", "implementationGuidance": "\nThe risks section may potentially contain sensitive information. Therefore, sufficient local role-based access controls should be in place to ensure this information is only shared with those care professionals where there is a need to do so.
\nThere may be situations where it not advisable to share information in this heading with the woman / birthing person to whom it relates. Appropriate policies and technical solutions must be in place for these situations.
\nAll information needs to be reviewed on a regular basis, but it is particularly important for this type of information, given its sensitive nature. There must be mechanisms in place to validate the information in this section and for it to be reviewed regularly.
\nSNOMED CT: - <281694009 |Finding of at risk (finding)|
\n\u00a0
\nFree text field to be used if no code is available, or to supplement the coded value with more information about the risk.\u00a0
", "valueSets": "Free text.", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Comment", "implementationGuidance": "Additional details about the risk.\u00a0", "description": "Additional details about the risk.\u00a0", "valueSets": "Free text", "valueDomain": [{"type": "string", "property": [{"maxLength": "150"}]}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Fetal scan report", "implementationGuidance": "This heading contains details of any scans undertaken to the mother / birthing person throughout the pregnancy.
If recording details of an observation of multiple pregnancy, the free text field may be used to record details of rare quadruplets and more if clinical terminology is not available.
The estimated delivery date (EDD) confirmed by a scan should supersede and take precedence over the EDD recoded under the pregnancy status section. It is important that EDD confirmed via a scan updates the EDD method as well as EDD in a system.
Group containing data items from a fetal scan report
\n ", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date scan offered", "implementationGuidance": "The date that the scan was offered.", "description": "The date that the scan was offered.
", "valueDomain": [{"type": "datetime"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Scan offer status", "implementationGuidance": "This relates to whether the scan itself has been offered and the outcome of that offer. It does not relate to whether an offer has been made for a specific date for the scan to take place.
", "description": "Whether or not the scan was offered, and the subsequent response to the offer
", "valueSets": "NHS Data Dictionary:- ACTIVITY OFFER STATUS
"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Fetal scan date and time", "implementationGuidance": "Concept", "description": "Concept", "valueSets": "\nDate and time
\n ", "valueDomain": [{"type": "datetime"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Type of scan", "implementationGuidance": "Type of fetal scan", "description": "\nType of fetal scan
\n ", "valueSets": "\nSNOMED CT
\n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Estimated delivery date (EDD)", "implementationGuidance": "Estimated delivery date", "description": "Estimated delivery date", "valueSets": "\nDate
\n ", "valueDomain": [{"type": "date"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Fetal order", "implementationGuidance": "Fetal order", "description": "Fetal order", "valueSets": "\nFetal order
\n ", "valueDomain": [{"type": "count"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Local Fetal Identifier", "implementationGuidance": "The unique identifier allocated to a fetus, which remains consistent throughout the pregnancy which allows the foetus to be identified in the event of multiple births, and in turn allow specific conditions to be attributed to a specific fetus and linked to labour/antenatal test details", "description": "\nThe unique identifier allocated to a fetus, which remains consistent throughout the pregnancy which allows the foetus to be identified in the event of multiple births, and in turn allow specific conditions to be attributed to a specific fetus and linked to labour/antenatal test details
\n ", "valueSets": "\nUnique identifier
\n ", "valueDomain": [{"type": "identifier"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Fetal movements", "implementationGuidance": "Fetal movements", "description": "Fetal movements", "valueSets": "\nFree text
\n ", "valueDomain": [{"type": "text"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Fetal presentation", "implementationGuidance": "Fetal presentation", "description": "Fetal presentation", "valueSets": "\nFree text
\n ", "valueDomain": [{"type": "text"}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Multiple pregnancy", "implementationGuidance": "Multiple pregnancy", "description": "Multiple pregnancy", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "Coded value for multiple pregnancy", "description": "\nCoded value for multiple pregnancy
\n ", "valueSets": "\nSNOMED CT
\n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text", "description": "Free text", "valueSets": "\nFree text
\n ", "valueDomain": [{"type": "text"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Head and neck findings details", "implementationGuidance": "Head and neck findings details", "description": "Head and neck findings details", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Head and neck", "implementationGuidance": "Head and neck", "description": "Head and neck", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "Coded value for head and neck findings", "description": "\nCoded value for head and neck findings
\n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text if no coded value available", "description": "\nFree text if no coded value available
\n ", "valueDomain": [{"type": "text"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Head shape", "implementationGuidance": "Head shape", "description": "Head shape", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "Coded value for head shape findings", "description": "\nCoded value for head shape findings
\n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text for use if no coded value available", "description": "\nFree text for use if no coded value available
\n ", "valueDomain": [{"type": "text"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Cavum septum pellucidum (CSP)", "implementationGuidance": "Cavum septum pellucidum (CSP)", "description": "Cavum septum pellucidum (CSP)", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "Coded value for Cavum septum pellucidum (CSP) findings", "description": "\nCoded value for Cavum septum pellucidum (CSP) findings
\n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text for use if coded value is not available", "description": "\nFree text for use if coded value is not available
\n ", "valueDomain": [{"type": "text"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Ventricular atrium (VA)", "implementationGuidance": "Ventricular atrium (VA)", "description": "Ventricular atrium (VA)", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "Coded value for Ventricular Atrium (VA) findings", "description": "\nCoded value for Ventricular Atrium (VA) findings
\n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text if no coded value available", "description": "\nFree text if no coded value available
\n ", "valueDomain": [{"type": "text"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Atrium of the lateral ventricle", "implementationGuidance": "Atrium of the lateral ventricle", "description": "Atrium of the lateral ventricle", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "Coded value for Atrium of the lateral Ventricle findings", "description": "\nCoded value for Atrium of the lateral Ventricle findings
\n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text for use if coded value not available", "description": "\nFree text for use if coded value not available
\n ", "valueDomain": [{"type": "text"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Cerebellum", "implementationGuidance": "Cerebellum", "description": "Cerebellum", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "Coded value for Cerebellum findings", "description": "\nCoded value for Cerebellum findings
\n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text for use if coded value unavailable", "description": "\nFree text for use if coded value unavailable
\n ", "valueSets": "\nFree text
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\n ", "valueDomain": [{"type": "count"}]}]}, {"type": "group", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "M", "name": "Previous pregnancy loss between 13 and 24 weeks", "implementationGuidance": "Details of the number of previous pregnancy loss between 13 and 24 weeks.", "description": "Details of the number of previous pregnancy loss between 13 and 24 weeks.
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\n ", "valueDomain": [{"type": "count"}]}]}, {"type": "group", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "M", "name": "Previous caesarean births", "implementationGuidance": "Details of the number of previous caesarean births.", "description": "Details of the number of previous caesarean births.
", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Previous caesarean births coded value", "implementationGuidance": "Coded value for number of previous caesarean births.", "description": "Coded value for number of previous caesarean births.
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\n ", "valueDomain": [{"type": "text"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Transitional care", "implementationGuidance": "Details of any transitional care", "description": "\nDetails of any transitional care
\n ", "valueDomain": [{"type": "text"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Actual place of birth", "implementationGuidance": "Actual place of birth", "description": "Actual place of birth", "valueDomain": [{"type": "text"}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Location of Birth", "implementationGuidance": "The place the baby was born.", "description": "The place the baby was born.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for location of birth.", "description": "The coded value for location of birth.", "valueSets": "NHS Data Dictionary: -\u00a0 Site Code (of Actual Place of Delivery) \nDetails of labour onset
\n ", "valueDomain": [{"type": "text"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Length of Labour", "implementationGuidance": "Length of labour should be stored in minutes, but displayed in hours and minutes.
", "description": "The length of the stages of labour and duration of the rupture of membranes (derived field)", "valueDomain": [{"type": "string"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Perineal Tear severity", "implementationGuidance": "Perineal tear severity", "description": "\nPerineal tear severity
\n ", "valueDomain": [{"type": "text"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Anaesthesia type", "implementationGuidance": "The specific type of anaesthesia used to carry out the procedure (if applicable)", "description": "The specific type of anaesthesia used to carry out the procedure (if applicable)", "valueDomain": [{"type": "string"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Types of delivery (attempted)", "implementationGuidance": "The type(s) of delivery for the baby that was attempted, but was not the final delivery method", "description": "The type(s) of delivery for the baby that was attempted, but was not the final delivery method", "valueDomain": [{"type": "text"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Genital Tract Trauma during labour or birth", "implementationGuidance": "Genital Tract Trauma during labour or birth", "description": "Genital Tract Trauma during labour or birth", "valueDomain": [{"type": "text"}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Episiotomy performed reason", "implementationGuidance": "Episiotomy performed reason", "description": "Episiotomy performed reason", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "Coded value for episiotomy performed reason", "description": "\nCoded value for episiotomy performed reason
\n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text to be used if no coded value available", "description": "\nFree text to be used if no coded value available
\n ", "valueDomain": [{"type": "text"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Birth experience", "implementationGuidance": "Birth experience", "description": "Birth experience", "valueDomain": [{"type": "text"}]}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Perinatal pelvic health", "implementationGuidance": "This section records information that is relevant to the perinatal pelvic health of the woman/birthing person.
", "description": "\nGroup containing data concepts relating to perinatal pelvic health
\n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Perinatal pelvic health record entry", "implementationGuidance": "Perinatal pelvic floor record entry", "description": "Perinatal pelvic floor record entry", "informationType": "\n <p>Event.Record</p> \n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "History of instrumental birth", "implementationGuidance": "History of instrumental birth", "description": "History of instrumental birth", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "Coded value for the instrumental birth", "description": "\nCoded value for the instrumental birth
\n ", "valueSets": "\nSNOMED CT
\n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text to be used if no coded value available", "description": "\nFree text to be used if no coded value available
\n ", "valueSets": "\nFree text
\n ", "valueDomain": [{"type": "text"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "History of perineal trauma", "implementationGuidance": "History of perineal trauma", "description": "History of perineal trauma", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Perineal trauma severity", "implementationGuidance": "Perineal trauma severity", "description": "Perineal trauma severity", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "Coded value for perineal trauma severity", "description": "\nCoded value for perineal trauma severity
\n ", "valueSets": "\nSNOMED CT
\n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text to be used if no coded value available", "description": "\nFree text to be used if no coded value available
\n ", "valueSets": "\nFree text
\n ", "valueDomain": [{"type": "text"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "History of Episiotomy", "implementationGuidance": "History of Episiotomy", "description": "History of Episiotomy", "valueSets": "\nFree text
\n ", "valueDomain": [{"type": "text"}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Pelvic floor symptoms record entry", "implementationGuidance": "Pelvic floor symptoms record entry", "description": "Pelvic floor symptoms record entry", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Incontinence", "implementationGuidance": "A record of whether the person experiences incontinence.", "description": "\nA record of whether the person experiences incontinence.
\n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Bowels", "implementationGuidance": "Bowels", "description": "Bowels", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Faecal incontinence", "implementationGuidance": "Faecal incontinence", "description": "Faecal incontinence", "valueSets": "\nFree text
\n ", "valueDomain": [{"type": "text"}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Problems or concerns with bowels", "implementationGuidance": "Any problems or concerns that the patient has in regard to their bowels. This includes if the problem is ongoing or new.", "description": "\nAny problems or concerns that the patient has in regard to their bowels. This includes if the problem is ongoing or new.
\n ", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "Coded value for problems with bowels.", "description": "\nCoded value for problems with bowels.
\n ", "valueSets": "\nSNOMED CT.
\n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text if coded value isn't available.", "description": "\nFree text if coded value isn't available.
\n ", "valueSets": "\nFree text.
\n ", "valueDomain": [{"type": "string"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Urination", "implementationGuidance": "Information relating to the person's urine and urination.", "description": "\nInformation relating to the person's urine and urination.
\n ", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Urinary incontinence", "implementationGuidance": "Urinary incontinence", "description": "Urinary incontinence", "valueSets": "\nFree text
\n ", "valueDomain": [{"type": "text"}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Problems or concerns with urination", "implementationGuidance": "Any problems or concerns that the patient has in regard to urination or their urine. This includes if the problem is ongoing or new.", "description": "\nAny problems or concerns that the patient has in regard to urination or their urine. This includes if the problem is ongoing or new.
\n ", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "Coded value for problems with urination.", "description": "\nCoded value for problems with urination.
\n ", "valueSets": "\nSNOMED CT.
\n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text if coded value isn't available.", "description": "\nFree text if coded value isn't available.
\n ", "valueSets": "\nFree text.
\n ", "valueDomain": [{"type": "string"}]}]}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Sexual symptoms or dysfunction", "implementationGuidance": "Sexual symptoms or dysfunction", "description": "Sexual symptoms or dysfunction", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "Coded value for sexual symptoms or dysfunction", "description": "\nCoded value for sexual symptoms or dysfunction
\n ", "valueSets": "\nSNOMED CT.
\n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text if coded value isn't available.", "description": "\nFree text if coded value isn't available.
\n ", "valueSets": "\nFree text.
\n ", "valueDomain": [{"type": "string"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Pelvic organ prolapse", "implementationGuidance": "Pelvic organ prolapse", "description": "Pelvic organ prolapse", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "Coded value for pelvic organ prolapse", "description": "\nCoded value for pelvic organ prolapse
\n ", "valueSets": "\nSNOMED CT
\n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text if no coded value available", "description": "\nFree text if no coded value available
\n ", "valueSets": "\nFree text
\n "}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Vulval or vaginal symptoms", "implementationGuidance": "Vulval or vaginal symptoms", "description": "Vulval or vaginal symptoms", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "Coded value for vulval or vaginal symptoms", "description": "\nCoded value for vulval or vaginal symptoms
\n ", "valueSets": "\nSNOMED CT
\n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Concept", "description": "Concept", "valueSets": "\nFree text
\n ", "valueDomain": [{"type": "text"}]}]}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Social context", "implementationGuidance": "\nThis section may be used to record the way in which the person is in contact with the criminal justice system.
\nSocial factors within the household, including the household composition and environmental factors, should be detailed within this section. Factual concerns about the environment, which are not specifically safeguarding, but may impinge upon it, MAY be recorded here. For example, serious lack of hygiene in the home, etc.
\nIf it is identified that the woman / birthing person\u2019s partner is subject to heavy alcohol consumption, it is recommended that they should be referred to specialist services. However, this information would be based on the partners consent and the information would be subsequently added to the partner\u2019s record not the woman / birthing person\u2019s.
\nThe alcohol and tobacco information models used as part of the Digital Maternity Record Standard are based on models developed outside the maternity project but have been adapted by specialists to suit use in the maternity care setting.
\nAdditional SNOMED CT reference sets may be published at a later date to support the recording of the social context information. For example, smoking status within the household, and substance misuse status within the household
\nWith regards to alcohol related information, the drinking habits prior to any pregnancy should be considered. Where a woman / birthing person has been pregnant twice in the period prior to the current pregnancy, then alcohol consumption prior to the first pregnancy should be recorded. The purpose of this is to record normal drinking patterns, i.e. when\n not pregnant.
\nCurrent alcohol consumption, alcohol consumption prior to pregnancy and alcohol consumption during the first few weeks of pregnancy should be recorded. Where frequency of alcohol consumption and frequency of binge drinking is greater than one a week then actual number of days should be recorded. Assessments such as \u2018Alcohol Use Disorder Identification\n Test for Consumption\u2019 AUDIT C may be used to confirm the woman / birthing person\u2019s alcohol consumption and status. This information should be recorded within the Assessments section
\nPrevious and current drug and substance use should be recorded under this element. This should include all substances that are considered harmful to the woman/birthing person and misused including illegal drugs and prescription drugs such as methadone.
\n ", "description": "Details of the person's drug and substance use.", "informationType": "Event.Record", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Drug/substance use", "implementationGuidance": "Latest or current drug/substance use.", "description": "Latest or current drug/substance use.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for drug and substance misuse.", "description": "The coded value for drug and substance misuse.", "valueSets": "\nSocial factors within the household, including the household composition and environmental factors, should be detailed within this section. Factual concerns about the environment, which are not specifically safeguarding, but may impinge upon it, MAY be recorded here. For example, serious lack of hygiene in the home, etc.
\n ", "description": "Factors in the household which impact the person's health and wellbeing, to include smoking in the home, alcohol/substance use etc.", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"minLength": "3", "maxLength": "5"}]}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Legal information", "implementationGuidance": "\nThis section allows for the recording of any relevant legal information including: Deprivation of Liberty Safeguards, Looked After Child status and Mental Health Act sections.
\nAny assessments performed such as a mental capacity assessment will show under the Assessments section.
\nIf there is no end date on any of the legal information recorded under this section, then this should be considered active.
\nThe documentation may be available centrally as part of shared care records or held locally as part of the persons health and care records.
\nSystems should allow copies of legal documentation to be attached to the record where it would be necessary to see copies of the original documents.
\nDetails on how consent was obtained
\n ", "valueDomain": [{"type": "text"}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Consent form details", "implementationGuidance": "A record of documents used to record consent for an intervention.", "description": "A record of documents used to record consent for an intervention.", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Consent form type", "implementationGuidance": "Record of consent form used.", "description": "Record of consent form used.This is a consent attendance details record entry.\u00a0\u00a0There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items
\n ", "informationType": "Event.Record", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professionals present", "implementationGuidance": "The name, role of the additional individuals or team members including consultant(s), nurse consultant(s), allied health professional(s), social worker(s)", "description": "The name, role of the additional individuals or team members including consultant(s), nurse consultant(s), allied health professional(s), social worker(s)", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "implementationGuidance": "The name of the professional present", "description": "The name of the professional present", "valueSets": "Free text", "valueDomain": [{"type": "string", "property": [{"maxLength": "70"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "implementationGuidance": "The role of the professional present.", "description": "The role of the professional present.", "valueSets": "\nAlignment to the workforce dataset NHS Occupation codes primarily is advised. Where no code is available, free text may be used.
\nNational Workforce Data Set (NWD) NHS Occupation codes are found here: -\u00a0https://digital.nhs.uk/data-and-information/data-collections-and-data-sets/data-sets/national-workforce-data-set-nwd-and-nhs-occupation-codes. To access the list of roles, download the 'NWD dataset specification' using the link on the page.
\nThe Staff Groups and Job Roles are listed in the \u2018NWD Class & Codes Appendix\u2019 tab of the attached NWD Dataset from row 640. The 'Staff Group' and 'Job Role' segments are contained in one field named 'Job' which work together e.g. Staff Group = Nursing & Midwifery Registered and Job Role = Staff Nurse.
\n \n "}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Other Individual Present", "implementationGuidance": "Details of non health care professionals present", "description": "\nDetails of non health care professionals present
\n ", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "implementationGuidance": "Name of other individuals present at the birth of the baby", "description": "\nName of other individuals present at the birth of the baby
\n ", "valueSets": "Free text.The reason Consent withdrawn
\n ", "valueDomain": [{"type": "text"}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Consent form details", "implementationGuidance": "A record of documents used to record consent for an intervention.", "description": "A record of documents used to record consent for an intervention.", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Consent form type", "implementationGuidance": "Record of consent form used.", "description": "Record of consent form used.This is a consent attendance details record entry.\u00a0\u00a0There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items
\n ", "informationType": "Event.Record", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Professionals present", "implementationGuidance": "The name, role of the additional individuals or team members including consultant(s), nurse consultant(s), allied health professional(s), social worker(s)", "description": "The name, role of the additional individuals or team members including consultant(s), nurse consultant(s), allied health professional(s), social worker(s)", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "implementationGuidance": "The name of the professional present", "description": "The name of the professional present", "valueSets": "Free text", "valueDomain": [{"type": "string", "property": [{"maxLength": "70"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "implementationGuidance": "The role of the professional present.", "description": "The role of the professional present.", "valueSets": "\nAlignment to the workforce dataset NHS Occupation codes primarily is advised. Where no code is available, free text may be used.
\nNational Workforce Data Set (NWD) NHS Occupation codes are found here: -\u00a0https://digital.nhs.uk/data-and-information/data-collections-and-data-sets/data-sets/national-workforce-data-set-nwd-and-nhs-occupation-codes. To access the list of roles, download the 'NWD dataset specification' using the link on the page.
\nThe Staff Groups and Job Roles are listed in the \u2018NWD Class & Codes Appendix\u2019 tab of the attached NWD Dataset from row 640. The 'Staff Group' and 'Job Role' segments are contained in one field named 'Job' which work together e.g. Staff Group = Nursing & Midwifery Registered and Job Role = Staff Nurse.
\n "}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Other Individual Present", "implementationGuidance": "Details of non health care professionals present", "description": "\nDetails of non health care professionals present
\n ", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "implementationGuidance": "Name of other individuals present at the birth of the baby", "description": "\nName of other individuals present at the birth of the baby
\n ", "valueSets": "Free text.This is a consent attendance details record entry.\u00a0\u00a0There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items
\n ", "informationType": "Event.Record", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Professionals present", "implementationGuidance": "The name, role of the additional individuals or team members including consultant(s), nurse consultant(s), allied health professional(s), social worker(s)", "description": "The name, role of the additional individuals or team members including consultant(s), nurse consultant(s), allied health professional(s), social worker(s)", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "implementationGuidance": "The name of the professional present", "description": "The name of the professional present", "valueSets": "Free text", "valueDomain": [{"type": "string", "property": [{"maxLength": "70"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "implementationGuidance": "The role of the professional present.", "description": "The role of the professional present.", "valueSets": "\nAlignment to the workforce dataset NHS Occupation codes primarily is advised. Where no code is available, free text may be used.
\nNational Workforce Data Set (NWD) NHS Occupation codes are found here: -\u00a0https://digital.nhs.uk/data-and-information/data-collections-and-data-sets/data-sets/national-workforce-data-set-nwd-and-nhs-occupation-codes. To access the list of roles, download the 'NWD dataset specification' using the link on the page.
\nThe Staff Groups and Job Roles are listed in the \u2018NWD Class & Codes Appendix\u2019 tab of the attached NWD Dataset from row 640. The 'Staff Group' and 'Job Role' segments are contained in one field named 'Job' which work together e.g. Staff Group = Nursing & Midwifery Registered and Job Role = Staff Nurse.
\n "}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Other Individual Present", "implementationGuidance": "Details of non health care professionals present", "description": "\nDetails of non health care professionals present
\n ", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "implementationGuidance": "Name of other individuals present at the birth of the baby", "description": "\nName of other individuals present at the birth of the baby
\n ", "valueSets": "Free text.Mental capacity needs to be assessed at each moment where treatment decisions need to be made. Hence there should be provisions for more than one MCA to be recorded.
\nMental Capacity Act 2005 (England and Wales)
\nAdults with Incapacity Act 2000 (Scotland)
\nMental Capacity Act 2016 (Northern Ireland).
\nIf there is a need to communicate the outcome of a mental capacity assessment it is important to record to which specific decision it relates.
\nDetails of the persons mental capacity assessment(s)
\n ", "informationType": "Event.Record", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Mental capacity assessment detail ", "implementationGuidance": "Whether an assessment of the mental capacity of the (adult) person has been undertaken, if so, what capacity the decision relates to and the outcome of the assessment. Also record best interests decision if person lacks capacity. There can be multiple assessments carried out for a person over time.", "description": "\nWhether an assessment of the mental capacity of the (adult) person has been undertaken, if so, what capacity the decision relates to and the outcome of the assessment. Also record best interests decision if person lacks capacity. There can be multiple assessments carried out for a person over time.
\n ", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Location of document", "implementationGuidance": "The location of the mental capacity assessment information.", "description": "The location of the mental capacity assessment information.", "valueSets": "Free text or URL", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Lasting power of attorney or court-appointed deputy record entry", "implementationGuidance": "\nLasting power of attorney (LPA) should include details of one or more people who have been given power by the person when they had capacity to make decisions about their health and welfare should they lose capacity to make those decisions. To be valid, an LPA must have been registered with the Court of Protection. If life- sustaining treatment is being considered\n the LPA document must state specifically that the attorney has been given power to consent to or refuse life-sustaining treatment.
\n ", "description": "Details of the person's LPA record or equivalent for either decision-making related to personal welfare or property and financial affairs. A person can have a maximum of two record entries, e.g. one for personal welfare and one for property and financial affairs. The record identifies if the representative appointed\n to act on the behalf of the individual is either their nominated legal representative, under a lasting power of attorney, or a court-appointed deputy.
", "informationType": "Event.Record <br clear=\"none\"/> \n ", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date", "implementationGuidance": "The date the LPA was recorded", "description": "The date the LPA was recorded", "valueSets": "Date and time", "valueDomain": [{"type": "datetime", "property": [{"timeStampPrecision": "YMDHM"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Lasting power of attorney detail", "implementationGuidance": "Record of one or more people who have been given power (LPA) by the person when they had capacity to make decisions about their health and welfare should they lose capacity to make those decisions. To be valid, an LPA must have been registered with the Court of Protection. If life-sustaining treatment is being considered the LPA document must state specifically that the attorney has been given power to consent to or refuse life-sustaining treatment. Details of any person (deputy) appointed by the court to make decisions about the person\u2019s health and welfare. A deputy does not have the power to refuse life-sustaining treatment.", "description": "Record of one or more people who have been given power (LPA) by the person when they had capacity to make decisions about their health and welfare should they lose capacity to make those decisions. To be valid, an LPA must have been registered with the Court of Protection. If life-sustaining treatment is being\n considered the LPA document must state specifically that the attorney has been given power to consent to or refuse life-sustaining treatment. Details of any person (deputy) appointed by the court to make decisions about the person\u2019s health and welfare. A deputy does not have the power to refuse life-sustaining treatment.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for the LPA", "description": "The coded value for the LPA", "valueSets": "SNOMED CT
816361000000101 | Has appointed person with personal welfare lasting power of attorney (Mental Capacity Act 2005) (finding) |
816341000000102 | Has appointed person with property and affairs lasting power of attorney (Mental Capacity Act 2005) (finding)\n |
765181000000102 | Consent given by Court of Protection appointed welfare deputy (finding) |
"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Location of document", "implementationGuidance": "The location of the LPA information", "description": "The location of the LPA information", "valueSets": "Free text or URL", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name of LPA", "implementationGuidance": "The names of any appointed people or deputies", "description": "The names of any appointed people or deputies", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "implementationGuidance": "The contact details of the LPA", "description": "The contact details of the LPA", "valueSets": "NHS data dictionary:- UK telephone number \n ", "valueDomain": [{"type": "string", "property": [{"maxLength": "35"}]}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Lasting power of attorney for property and financial affairs or court-appointed deputy (or equivalent)", "implementationGuidance": "Details of the person's LPA record or equivalent", "description": "Details of the person's LPA record or equivalent", "informationType": "Event.Record <br clear=\"none\"/> \n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Lasting power of attorney detail", "implementationGuidance": "Record of one or more people who have been given power (LPA) by the person when they had capacity to make decisions about their property and financial affairs should they lose capacity to make those decisions. To be valid, an LPA must have been registered with the Court of Protection. If life-sustaining treatment is being considered the LPA document must state specifically that the attorney has been given power to consent to or refuse life-sustaining treatment. Details of any person (deputy) appointed by the court to make decisions about the person\u2019s property and financial affairs. A deputy does not have the power to refuse life-sustaining treatment.", "description": "Record of one or more people who have been given power (LPA) by the person when they had capacity to make decisions about their property and financial affairs should they lose capacity to make those decisions. To be valid, an LPA must have been registered with the Court of Protection. If life-sustaining treatment\n is being considered the LPA document must state specifically that the attorney has been given power to consent to or refuse life-sustaining treatment. Details of any person (deputy) appointed by the court to make decisions about the person\u2019s property and financial affairs. A deputy does not have the power to refuse life-sustaining treatment.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for the LPA", "description": "The coded value for the LPA", "valueSets": "SNOMED CT: -\u00a0341041000000103 | Lasting power of attorney property and affairs (observable entity) |"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Location of document", "implementationGuidance": "The location of the LPA information", "description": "The location of the LPA information", "valueSets": "Free text or URL", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name of LPA", "implementationGuidance": "The names of any appointed people or deputies", "description": "The names of any appointed people or deputies", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "implementationGuidance": "The contact details of the LPA", "description": "The contact details of the LPA", "valueSets": "NHS data dictionary:- UK telephone number \n ", "valueDomain": [{"type": "string", "property": [{"maxLength": "35"}]}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Deprivation of Liberty Safeguards or equivalent record entry", "implementationGuidance": "\nLasting power of attorney (LPA) should include details of one or more people who have been given power by the person when they had capacity to make decisions about their health and welfare should they lose capacity to make those decisions. To be valid, an LPA must have been registered with the Court of Protection. If life- sustaining treatment is being considered\n the LPA document must state specifically that the attorney has been given power to consent to or refuse life-sustaining treatment.
\n ", "description": "Details of the person's Deprivation of Liberty Safeguards (DoLS) or equivalent", "informationType": "Event.Record", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Application date", "implementationGuidance": "The date the application was made", "description": "The date the application was made", "valueSets": "Date and time", "valueDomain": [{"type": "datetime", "property": [{"timeStampPrecision": "YMDHM"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Application status", "implementationGuidance": "The status of the DOLs application.", "description": "The status of the DOLs application.", "valueSets": "Free text : - Requested or authorised", "valueDomain": [{"type": "string", "property": [{"maxLength": "10"}], "example": [{"type": "valid", "#text": "Requested"}, {"type": "valid", "#text": "Authorised"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Deprivation of liberty safeguards or equivalent detail", "implementationGuidance": "Record of Deprivation of Liberty Safeguards (DoLS) or equivalent, including the reason for this.", "description": "Record of Deprivation of Liberty Safeguards (DoLS) or equivalent, including the reason for this.", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Start date of authorisation", "implementationGuidance": "The date the DOLs was authorised.", "description": "The date the DOLs was authorised.", "valueSets": "Data and time", "valueDomain": [{"type": "datetime", "property": [{"timeStampPrecision": "YMDHM"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Planned or actual end date of authorisation", "implementationGuidance": "The planned or actual end date of authorisation.", "description": "The planned or actual end date of authorisation.", "valueSets": "Date and time", "valueDomain": [{"type": "datetime", "property": [{"timeStampPrecision": "YMDHM"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Mental health act or equivalent status record entry", "implementationGuidance": "\nThis data item should include information pertaining to the Mental Health Act status of the woman / birthing person.
\nMental Capacity Act 2005 (England and Wales)
\nAdults with Incapacity Act 2000 (Scotland)
\nMental Capacity Act 2016 (Northern Ireland).
\nA clinician should satisfy themselves that the Advance Decision to Refuse Treatment (ADRT) is valid and that the circumstances that they are dealing with are those envisaged when the person made the ADRT. A valid and applicable ADRT is legally binding. The record should include the location of the legal document.
\n ", "description": "Details of the person's ADRT status.", "informationType": "Event.Record <br clear=\"none\"/> \n ", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date", "implementationGuidance": "The date the ADRT was recorded.", "description": "The date the ADRT was recorded.", "valueSets": "Date", "valueDomain": [{"type": "date", "property": [{"timeStampPrecision": "YMD"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Advance decision to refuse treatment detail", "implementationGuidance": "* A record of an advance decision to refuse one or more specific types of future treatment, made by a person who had capacity at the time of recording the decision. \n* The decision only applies when the person no longer has the capacity to consent to or refuse the specific treatment being considered. \n* An ADRT must be in writing, signed and witnessed. \n* If the ADRT is refusing life-sustaining treatment it must state specifically that the treatment is refused even if the person\u2019s life is at risk.", "description": "\nA record of an advance decision to refuse one or more specific types of future treatment, made by a person who had capacity at the time of recording the decision.
\nThe decision only applies when the person no longer has the capacity to consent to or refuse the specific treatment being considered.
\nAn ADRT must be in writing, signed and witnessed.
\nIf the ADRT is refusing life-sustaining treatment it must state specifically that the treatment is refused even if the person\u2019s life is at risk.
\nFree text or URL
Please refer to the latest published standard for this section.
", "description": "About me", "informationType": "Record"}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Additional support plans", "implementationGuidance": "\nIt must be possible to hold additional supporting plans, which may be linked to the care and support plan where the individual or care professional decides that the information should be available to others. Examples of additional supporting plans: asthma plan, mental health plan, tissue viability plan, nutrition plan, falls prevention plan, hospital or\n other service transfer of care plan, etc.
\nThis section allows for the recording of the woman / birthing person\u2019s birth plan if required. It is important to note that the way in which a birth plan is displayed may be dependent on local implementation. The source system may populate the management plan (plan and requested actions) with standardised care plans based on risks etc.
The format of additional supporting plans will vary according to the type of plan. Some may be structured and coded, some may include diagrams or images.
\nAdditional supporting plans should be available for others to view, but will only be created, updated and ended by the service creating the plan. These may be made available on the National Record Locator Service (NRL) in PDF format.
\nWhen an additional supporting plan is updated a new version of the plan may be linked to the care and support plan, again at the discretion of the individual or care professional.
\nEducational and health care plans are produced for people with neurodevelopmental conditions and apply up to the age of 25. However, they transition into adult services earlier so it is important to note that this plan may exist at the same time as a care and support plan.
\nThe name of the particular additional supporting plan, for example dieticians plan, wound management plan, discharge management plan and behaviour support plan.
\n ", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for the type of contingency plan", "description": "\nThe coded value for the type of contingency plan
\n ", "valueSets": "\nAlignment to the workforce dataset NHS Occupation codes primarily is advised. Where no code is available, free text may be used.
\nNational Workforce Data Set (NWD) NHS Occupation codes are found here: -\u00a0https://digital.nhs.uk/data-and-information/data-collections-and-data-sets/data-sets/national-workforce-data-set-nwd-and-nhs-occupation-codes. To access the list of roles, download the 'NWD dataset specification' using the link on the page.
\nThe Staff Groups and Job Roles are listed in the \u2018NWD Class & Codes Appendix\u2019 tab of the attached NWD Dataset from row 640. The 'Staff Group' and 'Job Role' segments are contained in one field named 'Job' which work together e.g. Staff Group = Nursing & Midwifery Registered and Job Role = Staff Nurse.
\n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "implementationGuidance": "Contact details of the professional (e.g. telephone number, email address etc.).", "description": "Contact details of the professional (e.g. telephone number, email address etc.).", "valueSets": "Free text", "valueDomain": [{"type": "string", "property": [{"maxLength": "35"}]}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Pregnancy status", "implementationGuidance": "This section contains information about the pregnancy status of the woman / birthing person, including their expected delivery date.
", "description": "\nGroup containing details of a person's pregnancy status
\n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Pregnancy status record entry", "implementationGuidance": "Pregnancy status record entry", "description": "Pregnancy status record entry", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Pregnancy state", "implementationGuidance": "Pregnancy state", "description": "Pregnancy state", "valueSets": "SNOMED CT
<<77386006 |Pregnancy (finding)| OR
60001007 |Not pregnant (finding)|
", "valueDomain": [{"type": "boolean"}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Estimated Delivery Date", "implementationGuidance": "Estimated Delivery Date", "description": "Estimated Delivery Date", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Estimated delivery date estimating method", "implementationGuidance": "Estimated delivery date estimated method", "description": "Estimated delivery date estimated method", "valueSets": "SNOMED CT
<161714006 |Estimated date of delivery (observable entity)|
"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Estimated delivery date", "implementationGuidance": "Estimated delivery date", "description": "Estimated delivery date", "valueSets": "SNOMED CT
<<161714006 |Estimated date of delivery (observable entity)|
", "valueDomain": [{"type": "date"}]}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Alerts", "implementationGuidance": "This section allows for the sharing of alerts. The alerts that are shared should be determined locally. They might, for example, include the presence of a medical implant, Group B Strep Alert, MRSA diagnosis or that a person requires reasonable adjustments. It is important that alerts are managed and removed when they are no longer relevant.\n The alerts displayed to users viewing the record may vary by use case and user\u2019s role.
", "description": "Details of alerts.", "informationType": "\n <p>Event.Record</p> \n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Alerts record entry", "implementationGuidance": "This is an alerts record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.", "description": "This is an alerts record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
", "informationType": "Event.Record", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Alert", "implementationGuidance": "Any significant information meriting a specific and highly visible warning to any user (e.g. metallic implant, potential dangerous pet).", "description": "Any significant information meriting a specific and highly visible warning to any user (e.g. metallic implant, potential dangerous pet).", "valueSets": "Free text", "valueDomain": [{"type": "string"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Diagnoses", "implementationGuidance": "Diagnoses", "description": "Diagnoses", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Diagnosis record entry", "implementationGuidance": "\nThis section allows for all relevant diagnoses, symptoms, conditions, 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.
\n\u2018Date of diagnosis made\u2019 should be included where available even if this is estimated in source systems.
\nWhen 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, \u2018dyspepsia\u2019 may be the diagnosis when a patient first presents with indigestion, upgraded to\n \u2018gastric ulcer\u2019 when this is found at endoscopy, and \u2018gastric cancer\u2019 when biopsies reveal this. 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\n 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.
\nCo-morbidities\u2019 should be shown as separate diagnoses. For example, dementia may be recorded as a primary diagnosis by a psycho-geriatrician, but as a co-morbidity where a patient is admitted for a hip replacement. Local implementations will need to define what will be prioritised according to each use case.
\nIn 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.
\nThis section includes the formulation. A formulation is an account, shared by a therapist and person, of the personal meaning and origins of a person\u2019s difficulties. This is viewed in the context of multiple factors including relationships, social circumstances and life events and will indicate the most helpful way forward.
\n ", "description": "Details of the person's formulation.", "informationType": "\n <p>Event.Record</p> \n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Formulation record entry", "implementationGuidance": "This is the formulation record entry. There may be 0 to many record entry/entries under a section. Each record entry is made up of a number of elements or data items.", "description": "This is the formulation record entry. There may be 0 to many record entry/entries under a section. Each record entry is made up of a number of elements or data items.", "informationType": "Event.Record", "concept": [{"type": "item", "minimumMultiplicity": "1", "maximumMultiplicity": "1", "mro": "M", "name": "Formulation", "implementationGuidance": "An account, shared by a therapist and person, of the personal meaning and origins of a person\u2019s difficulties. This is viewed in the context of multiple factors including relationships, social circumstances and life events and will indicate the most helpful way forward.", "description": "An account, shared by a therapist and person, of the personal meaning and origins of a person\u2019s difficulties. This is viewed in the context of multiple factors including relationships, social circumstances and life events and will indicate the most helpful way forward.", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Investigations requested", "implementationGuidance": "This section should be used to record investigations requested for both the woman / birthing person and the fetus.
This section should be used to record still birth investigations requested.
The section includes details of requested investigations as yet unfulfilled. This should include the reason and\n priority of the request.
Investigations that have concluded, and for which results are available, should be included in the investigation results section.
The observations section contents should be used for each instance of an observation in New Examination Results
\n ", "description": "\nGroup containing details of newborn examination results
\n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Newborn examination result record entry", "implementationGuidance": "Newborn examination result record entry", "description": "Newborn examination result record entry", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Weight", "implementationGuidance": "Observed Weight of newborn baby", "description": "\nObserved Weight of newborn baby
\n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Observations", "implementationGuidance": "The record of essential physiological measurements, e.g., heart rate, blood pressure, temperature, pulse, height, weight, respiratory rate, oxygen saturation.", "description": "The record of essential physiological measurements, e.g., heart rate, blood pressure, temperature, pulse, height, weight, respiratory rate, oxygen saturation.", "informationType": "\n <p>Event.Record</p> \n "}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Length of baby", "implementationGuidance": "Length of the new born baby", "description": "\nLength of the new born baby
\n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Observations", "implementationGuidance": "The record of essential physiological measurements, e.g., heart rate, blood pressure, temperature, pulse, height, weight, respiratory rate, oxygen saturation.", "description": "The record of essential physiological measurements, e.g., heart rate, blood pressure, temperature, pulse, height, weight, respiratory rate, oxygen saturation.", "informationType": "\n <p>Event.Record</p> \n "}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Head circumference", "implementationGuidance": "Head circumference of the new born baby", "description": "\nHead circumference of the new born baby
\n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Observations", "implementationGuidance": "The record of essential physiological measurements, e.g., heart rate, blood pressure, temperature, pulse, height, weight, respiratory rate, oxygen saturation.", "description": "The record of essential physiological measurements, e.g., heart rate, blood pressure, temperature, pulse, height, weight, respiratory rate, oxygen saturation.", "informationType": "\n <p>Event.Record</p> \n "}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Fontanelles", "implementationGuidance": "Fontanelles observation", "description": "\nFontanelles observation
\n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Observations", "implementationGuidance": "The record of essential physiological measurements, e.g., heart rate, blood pressure, temperature, pulse, height, weight, respiratory rate, oxygen saturation.", "description": "The record of essential physiological measurements, e.g., heart rate, blood pressure, temperature, pulse, height, weight, respiratory rate, oxygen saturation.", "informationType": "\n <p>Event.Record</p> \n "}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Spine", "implementationGuidance": "Spine observation", "description": "\nSpine observation
\n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Observations", "implementationGuidance": "The record of essential physiological measurements, e.g., heart rate, blood pressure, temperature, pulse, height, weight, respiratory rate, oxygen saturation.", "description": "The record of essential physiological measurements, e.g., heart rate, blood pressure, temperature, pulse, height, weight, respiratory rate, oxygen saturation.", "informationType": "\n <p>Event.Record</p> \n "}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Toes", "implementationGuidance": "Toes observation", "description": "\nToes observation
\n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Observations", "implementationGuidance": "The record of essential physiological measurements, e.g., heart rate, blood pressure, temperature, pulse, height, weight, respiratory rate, oxygen saturation.", "description": "The record of essential physiological measurements, e.g., heart rate, blood pressure, temperature, pulse, height, weight, respiratory rate, oxygen saturation.", "informationType": "\n <p>Event.Record</p> \n "}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Anus patency", "implementationGuidance": "Anus patency observations", "description": "\nAnus patency observations
\n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Observations", "implementationGuidance": "The record of essential physiological measurements, e.g., heart rate, blood pressure, temperature, pulse, height, weight, respiratory rate, oxygen saturation.", "description": "The record of essential physiological measurements, e.g., heart rate, blood pressure, temperature, pulse, height, weight, respiratory rate, oxygen saturation.", "informationType": "\n <p>Event.Record</p> \n "}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Genitalia", "implementationGuidance": "Genitalia observations", "description": "\nGenitalia observations
\n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Observations", "implementationGuidance": "The record of essential physiological measurements, e.g., heart rate, blood pressure, temperature, pulse, height, weight, respiratory rate, oxygen saturation.", "description": "The record of essential physiological measurements, e.g., heart rate, blood pressure, temperature, pulse, height, weight, respiratory rate, oxygen saturation.", "informationType": "\n <p>Event.Record</p> \n "}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Eyes", "implementationGuidance": "Eyes observations", "description": "\nEyes observations
\n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Observations", "implementationGuidance": "The record of essential physiological measurements, e.g., heart rate, blood pressure, temperature, pulse, height, weight, respiratory rate, oxygen saturation.", "description": "The record of essential physiological measurements, e.g., heart rate, blood pressure, temperature, pulse, height, weight, respiratory rate, oxygen saturation.", "informationType": "\n <p>Event.Record</p> \n "}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Ears", "implementationGuidance": "Ears observations", "description": "\nEars observations
\n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Observations", "implementationGuidance": "The record of essential physiological measurements, e.g., heart rate, blood pressure, temperature, pulse, height, weight, respiratory rate, oxygen saturation.", "description": "The record of essential physiological measurements, e.g., heart rate, blood pressure, temperature, pulse, height, weight, respiratory rate, oxygen saturation.", "informationType": "\n <p>Event.Record</p> \n "}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Palate", "implementationGuidance": "Palate observations", "description": "\nPalate observations
\n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Observations", "implementationGuidance": "The record of essential physiological measurements, e.g., heart rate, blood pressure, temperature, pulse, height, weight, respiratory rate, oxygen saturation.", "description": "The record of essential physiological measurements, e.g., heart rate, blood pressure, temperature, pulse, height, weight, respiratory rate, oxygen saturation.", "informationType": "\n <p>Event.Record</p> \n "}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Feet (talipes)", "implementationGuidance": "Feet (talipes) observations", "description": "\nFeet (talipes) observations
\n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Observations", "implementationGuidance": "The record of essential physiological measurements, e.g., heart rate, blood pressure, temperature, pulse, height, weight, respiratory rate, oxygen saturation.", "description": "The record of essential physiological measurements, e.g., heart rate, blood pressure, temperature, pulse, height, weight, respiratory rate, oxygen saturation.", "informationType": "\n <p>Event.Record</p> \n "}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Moro reflex", "implementationGuidance": "Moro reflex observations", "description": "\nMoro reflex observations
\n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Observations", "implementationGuidance": "The record of essential physiological measurements, e.g., heart rate, blood pressure, temperature, pulse, height, weight, respiratory rate, oxygen saturation.", "description": "The record of essential physiological measurements, e.g., heart rate, blood pressure, temperature, pulse, height, weight, respiratory rate, oxygen saturation.", "informationType": "\n <p>Event.Record</p> \n "}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "NIPE examination results", "implementationGuidance": "This section record the results of the Newborn Infant Physical Examination. This includes the eye examination, heart examination, hip examination, and testes examination.
", "description": "\nGroup containing details of NIPE examination results
\n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Newborn infant physical examination (NIPE) result record entry", "implementationGuidance": "Newborn infant physical examination (NIPE) result record entry", "description": "\nNewborn infant physical examination (NIPE) result record entry
\n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Eye Examination", "implementationGuidance": "Group containing the NIPE Eye Examination observations", "description": "\nGroup containing the NIPE Eye Examination observations
\n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Eye opening", "implementationGuidance": "Eye opening observation", "description": "\nEye opening observation
\n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Observations", "implementationGuidance": "The record of essential physiological measurements, e.g., heart rate, blood pressure, temperature, pulse, height, weight, respiratory rate, oxygen saturation.", "description": "The record of essential physiological measurements, e.g., heart rate, blood pressure, temperature, pulse, height, weight, respiratory rate, oxygen saturation.", "informationType": "\n <p>Event.Record</p> \n "}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Position and symmetry", "implementationGuidance": "Eye Position and symmetry observations", "description": "\nEye Position and symmetry observations
\n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Observations", "implementationGuidance": "The record of essential physiological measurements, e.g., heart rate, blood pressure, temperature, pulse, height, weight, respiratory rate, oxygen saturation.", "description": "The record of essential physiological measurements, e.g., heart rate, blood pressure, temperature, pulse, height, weight, respiratory rate, oxygen saturation.", "informationType": "\n <p>Event.Record</p> \n "}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Size and colour", "implementationGuidance": "Eye size and colour observations", "description": "\nEye size and colour observations
\n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Observations", "implementationGuidance": "The record of essential physiological measurements, e.g., heart rate, blood pressure, temperature, pulse, height, weight, respiratory rate, oxygen saturation.", "description": "The record of essential physiological measurements, e.g., heart rate, blood pressure, temperature, pulse, height, weight, respiratory rate, oxygen saturation.", "informationType": "\n <p>Event.Record</p> \n "}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Red reflex (present / absent)", "implementationGuidance": "Eye red reflex (present / absent) observations", "description": "\nEye red reflex (present / absent) observations
\n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Observations", "implementationGuidance": "The record of essential physiological measurements, e.g., heart rate, blood pressure, temperature, pulse, height, weight, respiratory rate, oxygen saturation.", "description": "The record of essential physiological measurements, e.g., heart rate, blood pressure, temperature, pulse, height, weight, respiratory rate, oxygen saturation.", "informationType": "\n <p>Event.Record</p> \n "}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Heart Examination", "implementationGuidance": "Group containing the observation from the NIPE Heart Examination", "description": "\nGroup containing the observation from the NIPE Heart Examination
\n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Observation / appearance", "implementationGuidance": "Heart Observation / appearance from the NIPE", "description": "\nHeart Observation / appearance from the NIPE
\n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Observations", "implementationGuidance": "The record of essential physiological measurements, e.g., heart rate, blood pressure, temperature, pulse, height, weight, respiratory rate, oxygen saturation.", "description": "The record of essential physiological measurements, e.g., heart rate, blood pressure, temperature, pulse, height, weight, respiratory rate, oxygen saturation.", "informationType": "\n <p>Event.Record</p> \n "}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Palpitation", "implementationGuidance": "Heart Palpitation observations from the NIPE", "description": "\nHeart Palpitation observations from the NIPE
\n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Examination findings", "implementationGuidance": "Examination findings", "description": "Examination findings"}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": [{"language": "en-GB"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Auscultation", "implementationGuidance": "Heart Auscultation examination findings from the NIPE", "description": "\nHeart Auscultation examination findings from the NIPE
\n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Examination findings", "implementationGuidance": "Examination findings", "description": "Examination findings"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Hip examination", "implementationGuidance": "Group containing observations from the NIPE Hip examination", "description": "\nGroup containing observations from the NIPE Hip examination
\n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Observation / appearance", "implementationGuidance": "Hip Observation / appearance observations from the NIPE", "description": "\nHip Observation / appearance observations from the NIPE
\n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Observations", "implementationGuidance": "The record of essential physiological measurements, e.g., heart rate, blood pressure, temperature, pulse, height, weight, respiratory rate, oxygen saturation.", "description": "The record of essential physiological measurements, e.g., heart rate, blood pressure, temperature, pulse, height, weight, respiratory rate, oxygen saturation.", "informationType": "\n <p>Event.Record</p> \n "}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Manipulation (Ortolani & Barlow)", "implementationGuidance": "Hip Manipulation (Ortolani & Barlow) examination findings from the NIPE", "description": "\nHip Manipulation (Ortolani & Barlow) examination findings from the NIPE
\n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Examination findings", "implementationGuidance": "Examination findings", "description": "Examination findings"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Testes examination", "implementationGuidance": "Group containing observations from the NIPE Testes examination", "description": "\nGroup containing observations from the NIPE Testes examination
\n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Scrotum (colour, size, and symmetry)", "implementationGuidance": "Scrotum (colour, size, and symmetry) observations from the NIPE", "description": "\nScrotum (colour, size, and symmetry) observations from the NIPE
\n "}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Scrotum (colour, size, and symmetry)", "implementationGuidance": "Testes palpation examination findings from the NIPE", "description": "\nTestes palpation examination findings from the NIPE
\n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": [{"language": "en-GB"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Scrotum (colour, size, and symmetry)", "implementationGuidance": "Observations from Scrotum (colour, size, and symmetry) from NIPE", "description": "\nObservations from Scrotum (colour, size, and symmetry) from NIPE
\n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Observations", "implementationGuidance": "The record of essential physiological measurements, e.g., heart rate, blood pressure, temperature, pulse, height, weight, respiratory rate, oxygen saturation.", "description": "The record of essential physiological measurements, e.g., heart rate, blood pressure, temperature, pulse, height, weight, respiratory rate, oxygen saturation.", "informationType": "\n <p>Event.Record</p> \n "}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Palpation", "implementationGuidance": "Testes Scrotum observations from the NIPE", "description": "\nTestes Scrotum observations from the NIPE
\n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Examination findings", "implementationGuidance": "Examination findings", "description": "Examination findings"}]}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Problem list", "implementationGuidance": "\nThis section allows for the recording of all relevant diagnoses and problems and issues.
\nThe naming of this section may be displayed differently in a system if it is felt that the current wording of \u2018problem list\u2019 has negative connotations.
\nAny dietary habits considered a problem or issue should be recorded under this section.
\nThis is an example list of conditions, problems and issues that may be recorded in the maternity setting and may be recorded under this heading: Social concerns; Mental Health concerns; Substance misuse; Type I or type II diabetes; Incompetent cervix; Hypertension requiring medication; Auto immune disorder; Cardiac disease, Haematological disorder;\n Thromboembolic.
\nAdditional concerns for MEWS should be captured in the problem list. This could then lead to a plan and requested action entered in the persons record.
\nThis is a summary of problems that require investigation or treatment. This would include significant examination findings, symptoms and signs, which are likely to have relevance and are not a diagnosis.
\nIt is recommended that coded items are included in the values for problem and issues.
\nThe format of the onset date of the diagnosis recorded should allow for partial dates, as the exact date may not be known.
\n ", "description": "A date or estimated date that the problem began", "valueSets": "Date and time", "valueDomain": [{"type": "datetime", "property": [{"timeStampPrecision": "YM"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "End Date", "implementationGuidance": "The date or estimated date the problem was resolved.", "description": "The date or estimated date the problem was resolved.", "valueSets": "Date and time.", "valueDomain": [{"type": "datetime", "property": [{"timeStampPrecision": "YMDHM"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Comment", "implementationGuidance": "Supporting text may be given covering the problem.", "description": "Supporting text may be given covering the problem.", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Complicating factor", "implementationGuidance": "The clinician should be presented with the pregnant person's list of current problems, from which they can select any that may have a complicating impact on the pregnancy.
", "description": "Factors that may negatively influence the course or outcome of a condition
", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Complicating factor record entry", "implementationGuidance": "Complicating factor record entry", "description": "Complicating factor record entry", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Impacted condition", "implementationGuidance": "The specific health condition or clinical episode affected by the complicating factor.", "description": "The specific health condition or clinical episode affected by the complicating factor.
", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Maternity episode details", "implementationGuidance": "Pregnancy episode details", "description": "Pregnancy episode details"}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Complicating factor", "implementationGuidance": "Factors that may negatively influence the course or outcome of the primary condition.", "description": "Factors that may negatively influence the course or outcome of the primary condition.
", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Problem", "implementationGuidance": "A condition which needs addressing and so is important for every professional to know about when seeing the person. \n \n Problems may include diagnoses, symptoms, and social or behavioural issues", "description": "A condition which needs addressing and so is important for every professional to know about when seeing the person.These are the details of any services that the woman / birthing person has been signposted to.\u00a0Signposting is in the form of providing the person with the name of an organisation and their contact details e.g. telephone number, website (it is not a referral).
", "description": "Details of signpost", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Signpost details record entry", "implementationGuidance": "This is the signpost details record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.", "description": "This is the signpost details record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.", "informationType": "Event.Record", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date", "implementationGuidance": "Date of signpost.", "description": "Date of signpost.", "valueSets": "\nDate and time
\n ", "valueDomain": [{"type": "datetime", "property": [{"timeStampPrecision": "YMD"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Signpost to", "implementationGuidance": "Details of where the signpost is to.\n \nIf not an individual, this could be a service.", "description": "Details of where the signpost is to.NHS data dictionary :- Activity treatment function code
\n ", "valueDomain": [{"type": "string", "property": [{"maxLength": "70"}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Service", "implementationGuidance": "The service signposted to.", "description": "The service signposted to.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for service.", "description": "The coded value for service.", "valueSets": "\n \n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text field to be used if no code is available.", "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": "Organisation name", "implementationGuidance": "The name of the organisation signposted to.", "description": "The name of the organisation signposted to.", "valueSets": "Free text.", "valueDomain": [{"type": "string", "property": [{"maxLength": "150"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Contact details", "implementationGuidance": "The contact details of where the person has been signposted to.", "description": "The contact details of where the person has been signposted to.", "valueSets": "Free text.", "valueDomain": [{"type": "string", "property": [{"maxLength": "150"}]}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Reason for signpost", "implementationGuidance": "The reason for signposting.", "description": "The reason for signposting.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for reason for signpost.", "description": "The coded value for reason for signpost.", "valueSets": "\n \n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text field to be used if no code is available.", "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": "Smoking record", "implementationGuidance": "This is the smoking record, where further information about the woman/birthing person's smoking habits are recorded. This includes information about quit dates, nicotine replacement therapy, use of e-cigarettes, and carbon monoxide screening.
Information about smoking is also captured in the Social Context section.
Once the woman/birthing person is identified as a smoker, the healthcare professional should complete this section to provide further details.
Nicotine replacement therapy (NRT) should be offered to all smokers and provision ensured as soon as possible.
", "description": "A record of whether nicotine replacement therapy (NRT) is currently used or prescribed in this appointment", "valueSets": "\nNRT not currently used
\nNRT currently used
\nNRT prescribed at this appointment
\n ", "valueDomain": [{"type": "text"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "e-cigarettes used", "implementationGuidance": "Record of current use of e-cigarettes", "description": "Record of current use of e-cigarettes", "valueSets": "\nCoded - SNOMED CT:
\n722499006 |Electronic cigarette user (finding)|
\n "}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date stopped smoking", "implementationGuidance": "The date the person stopped smoking (if known)", "description": "The date the person stopped smoking (if known)", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for date stopped smoking.", "description": "The coded value for date stopped smoking.", "valueSets": "\n \n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date", "implementationGuidance": "The date the person stopped smoking.", "description": "The date the person stopped smoking.", "valueSets": "Date and time", "valueDomain": [{"type": "date", "property": [{"timeStampPrecision": "YM"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Self reported quit", "implementationGuidance": "A flag to indicate whether the quit was self reported or not.", "description": "\nA flag to indicate whether the quit was self reported or not.
\n ", "valueSets": "\nYes/No
\n ", "valueDomain": [{"type": "boolean"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "CO Screening status", "implementationGuidance": "CO Screening status", "description": "\nCO Screening status
\n "}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "CO screening result", "implementationGuidance": "Instigate an opt-out referral for all women who have an elevated CO level (4ppm or above), who identify themselves as smokers or have quit in the last 2 weeks for treatment by a trained tobacco dependence treatment adviser (TDA) within an in-house tobacco dependence treatment service.
Investigation results
\n "}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Treatments and interventions", "implementationGuidance": "This section records information about any treatments and interventions that the woman/birthing person is undergoing.
This includes changes to treatments an interventions, and any discontinued treatments and interventions.
Start date of the treatment or intervention
\n ", "valueDomain": [{"type": "date"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "End date", "implementationGuidance": "Date the treatment or intervention ended", "description": "\nDate the treatment or intervention ended
\n ", "valueDomain": [{"type": "date"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Status", "implementationGuidance": "Status of the treatment or intervention", "description": "\nStatus of the treatment or intervention
\n "}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Comment", "implementationGuidance": "Comment relating to the treatment or intervention", "description": "\nComment relating to the treatment or intervention
\n "}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Treatments and interventions changes record entry.", "implementationGuidance": "The treatments and interventions carried out. Where appropriate record the rationale for the decision to treat and the information sources reviewed e.g. end of life care plan etc. All medications should be recorded under the medications heading.", "description": "The treatments and interventions carried out. Where appropriate record the rationale for the decision to treat and the information sources reviewed e.g. end of life care plan etc. All medications should be recorded under the medications heading.", "informationType": "\n <p>Event.Record</p> \n ", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for treatment and interventions.", "description": "The coded value for treatment and interventions.", "valueSets": "SNOMED CT"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text field to be used if no code is available", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date of change", "implementationGuidance": "Date of change of the treatment or intervention", "description": "\nDate of change of the treatment or intervention
\n ", "valueDomain": [{"type": "date"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "End date", "implementationGuidance": "Date the amended treatment or intervention ended", "description": "\nDate the amended treatment or intervention ended
\n ", "valueDomain": [{"type": "date"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Reason for change", "implementationGuidance": "Reason for change to the treatment / intervention", "description": "\nReason for change to the treatment / intervention
\n ", "valueDomain": [{"type": "text"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Status", "implementationGuidance": "Status of the treatment or intervention", "description": "\nStatus of the treatment or intervention
\n "}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Comment", "implementationGuidance": "Comment relating to the treatment or intervention", "description": "\nComment relating to the treatment or intervention
\n "}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Discontinued Treatments and interventions record entry.", "implementationGuidance": "The treatments and interventions carried out. Where appropriate record the rationale for the decision to treat and the information sources reviewed e.g. end of life care plan etc. All medications should be recorded under the medications heading.", "description": "The treatments and interventions carried out. Where appropriate record the rationale for the decision to treat and the information sources reviewed e.g. end of life care plan etc. All medications should be recorded under the medications heading.", "informationType": "\n <p>Event.Record</p> \n ", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for treatment and interventions.", "description": "The coded value for treatment and interventions.", "valueSets": "SNOMED CT"}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Free text", "implementationGuidance": "Free text field to be used if no code is available", "description": "Free text field to be used if no code is available", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "150"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date discontinued", "implementationGuidance": "Date of the treatment or intervention was discontinued", "description": "\nDate of the treatment or intervention was discontinued
\n ", "valueDomain": [{"type": "date"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Reason for discontinuation", "implementationGuidance": "Reason for discontinuation of the treatment or intervention", "description": "\nReason for discontinuation of the treatment or intervention
\n ", "valueDomain": [{"type": "text"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Status", "implementationGuidance": "Status of the treatment or intervention", "description": "\nStatus of the treatment or intervention
\n "}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Comment", "implementationGuidance": "Comment relating to the treatment or intervention", "description": "\nComment relating to the treatment or intervention
\n "}]}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Contingency plans", "implementationGuidance": "\nContingency/safety plans are known by other terms depending on care setting. In mental health for example, \u2018safety plans\u2019 is a commonly understood term while medically these are more commonly known as \u2018Contingency plans\u2019.
\nNot everyone who has a care and support plan will need a contingency/safety (also known as crisis/emergency/escalation/advance/anticipatory) plan.
\nThis plan is for those people who have specific and predictable risks associated with their health and wellbeing. It describes how disruptions to the care and support plan should be addressed.
\nThere may be a number of different contingency/safety plans to manage different aspects of health and wellbeing, e.g. diabetes, respiratory, mental health, substance misuse, etc. The plan may cover different scenarios, e.g. mild disruption/issues, through to more severe.
\nIt must be possible to create a contingency/safety plan at any time when the individual and those providing care and support identify a need for such a plan.
\nContingency/safety plans must be subject to or as a result of an assessment.
\nContingency/safety plans may include end of life care planning elements. These only form part of an initial conversation and a full end of life care plan should be included separately as an end of life care document.
\nThe \u2018Coping Strategies\u2019 element should include details of all coping strategies used in free text. Any tools used to carry out the coping strategy should be included here.
\nCoping strategies may need to be regularly updated as it may depend on the stage of recovery the person is at.
\nSigns to watch out for that may indicate a significant change in health or other circumstances. These could include physical health conditions, environmental factors, or mental health problems, (e.g. feeling anxious)
\n ", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The trigger that leads to instigation of\u00a0a significant change in health or other circumstances.", "description": "The trigger that leads to instigation of\u00a0a significant change in health or other circumstances.The name of the contingency plan
\n ", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "implementationGuidance": "The coded value for the type of contingency plan", "description": "\nThe coded value for the type of contingency plan
\n ", "valueSets": "\n