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draft Scenario Wound Care (0.1) 2.16.840.1.113883.3.1937.777.28.3.52

Name Details [‑]
draft Wound Care (0.1)
prsb03-scenario-52
Version / effective date 2022‑10‑26
Description

Information required to support the assessment, management, maintenance and prevention of, lower limb wounds, pressure ulcers and surgical wounds. The development of the standard has been commissioned by the National Wound Care Strategy Programme as a initiative to help address the marked unwarranted variation in UK wound care services, underuse of evidence-based practices and overuse of ineffective practices

draft doublearrow Wound care record
prsb03-transaction-433link
Version / effective date 2022‑10‑31 13:33:19    
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draft rotate Personal details
prsb03-transaction-434link
Version / effective date 2022‑10‑31 13:33:19    
Actor
stationary (person) Person
Associations
Contained concepts
Concept Card/Conf Id
folder Person demographics
1 … 1
prsb03-dataelement-10868link
The person's details and contact information.
treetree folder Person name
1 … 1
prsb03-dataelement-10869link
Details of the person's name
treeblank treetree draft  Person first name
1 … 1
prsb03-dataelement-13799link
The first name(s) of the person. This includes middle names.NHS data dictionary :- Person given name
treeblank treetree draft  Person family name
1 … 1
prsb03-dataelement-13800link
The family name or surname of the personNHS data dictionary : - Person family name
treeblank treetree draft  Person preferred name
0 … 1
prsb03-dataelement-10870link
The name by which a person wishes to be addressed. The preferred name volunteered by the person or a preferred name given by PDS that the person has asked to be called by.NHS data dictionary: - Person full name
treeblank treetree draft  Title
0 … 1
prsb03-dataelement-13089link
Person's titleNHS data dictionary: - Person Title
treeblank treetree draft  Person name suffix
0 … 1
prsb03-dataelement-13798link
A textual suffix that may be added to the end of a PERSON's name, for example, OBE, MBE, BSc, JP, GMNHS data dictionary: - Person suffix
treeblank treetree draft  Person full name
0 … 1
prsb03-dataelement-13801link
The full name of the person in text representation.NHS data dictionary :- Person full name
treetree draft  Date of birth
1 … 1
prsb03-dataelement-10871link
The date of birth of the person.NHS data dictionary:- Person birth date
treetree draft  Gender
0 … 1
prsb03-dataelement-10872link
The person's stated gender.NHS data dictionary :- Person stated gender code
treetree draft  Person alias
0 … *
prsb03-dataelement-10873link
Other name(s) associated with the person.Free text
treetree draft  Ethnicity
0 … 1
prsb03-dataelement-10874link
The ethnicity of the person as specified by the person.NHS data dictionary :- Ethnic category
treetree draft  Religion
0 … 1
prsb03-dataelement-10876link
The religious affiliation as specified by the person. SNOMED_CT:- Religion
treetree draft  Sex
0 … 1
prsb03-dataelement-10877link
The person’s phenotypic sex. Determines how the person will be treated clinically.NHS data dictionary: - person phenotypic sex
treetree draft  Carer Status
0 … 1
prsb03-dataelement-21924link
The carer status is important to ensure provision is put in place to support the person receiving and providing care.
Snomed CT Person themselves is a carer https://termbrowser.nhs.uk/?perspective=full&conceptId1=224484003&edition=uk-edition&release=v20211124&server=https://termbrowser.nhs.uk/sct-browser-api/snomed&langRefset=999001261000000100,999000691000001104
treetree draft  NHS number
0 … 1
prsb03-dataelement-10879link
The unique identifier for a person within the NHS in England and Wales.NHS data dictionary:- NHS number
treetree draft  Other identifier
0 … *
prsb03-dataelement-10880link
Country specific or local identifier, e.g. Community Health Index (CHI) in Scotland. NHS data dictionary: - Local patient identifier(extended), Health and care number (NI only), Community health index number (Scotland only)
treetree folder Person's address
1 … *
prsb03-dataelement-10881link
Person’s usual place of residence, and where relevant temporary and correspondence addresses.
treeblank treetree draft  Address line 1
1 … 1
prsb03-dataelement-13082link
Person's first line of address. NHS data dictionary :-  Address line 1
treeblank treetree draft  Address line 2
0 … 1
prsb03-dataelement-13083link
Person's second line of address. NHS data dictionary :- Address line 2
treeblank treetree draft  Address line 3
0 … 1
prsb03-dataelement-13084link
Person's third line of address. NHS data dictionary : - Address line 3
treeblank treetree draft  Address line 4
0 … 1
prsb03-dataelement-13085link
Person's fourth line of address. NHS data dictionary : - Address line 4
treeblank treetree draft  Address line 5
0 … 1
prsb03-dataelement-13086link
Person's fifth line of address.NHS data dictionary : - Address line 5
treeblank treetree draft  Postcode
1 … 1
prsb03-dataelement-13087link
The person's postcode.NHS data dictionary :- Postcode of usual address
treeblank treetree draft  Address type
0 … 1
prsb03-dataelement-13221link
The type of address e.g. Main address, Temp addressNHS data dictionary :- Address Association Type
treetree folder Person's contact details
0 … 1
prsb03-dataelement-13804link
Details of the person's contact information.
treeblank treetree draft  Preferred contact method
0 … 1
prsb03-dataelement-10886link
Preferred contact method, e.g. email, letter, phone, text message etc.NHS data dictionary:- Preferred Contact Method
treeblank treetree folder Person's telephone number details
0 … *
prsb03-dataelement-10883link
The person's telephone number details
treeblank treeblank treetree draft  Person's telephone number
0 … 1
prsb03-dataelement-13808link
The person's telephone numberNHS data dictionary : - UK telephone number
treeblank treeblank treetree draft  Person's telephone number type
0 … 1
prsb03-dataelement-13805link
The contact type e.g. home, mobileFHIR value set: - Contact point use
treeblank treeblank treetree draft  Preference of telephone number
0 … 1
prsb03-dataelement-13809link
The preferred order of use for the telephone numberPreference of use 1-5, 1 being the highest.
treeblank treetree folder Person's email address details
0 … *
prsb03-dataelement-13807link
Details of the person's email address
treeblank treeblank treetree draft  Person's email address
0 … 1
prsb03-dataelement-10882link
Email address of the person.NHS data dictionary:- Contact Email Address
treeblank treeblank treetree draft  Person's email address type
0 … 1
prsb03-dataelement-13811link
The type of email address, home, work.
FHIR value set: - Contact point use
treeblank treeblank treetree draft  Preference of email address
0 … 1
prsb03-dataelement-13810link
The preferred order of use of email addressPreference of use 1-5, 1 being the highest.
treeblank treetree draft  Other contact information
0 … *
prsb03-dataelement-13806link
Contact details via fax, sms, url.
NHS data dictionary:- Communication contact string
treetree draft  Photograph
0 … 1
prsb03-dataelement-13065link
A photograph of the person for identification and to show what the person looks like normally.Mulitmedia file
treetree draft  Place of birth
0 … 1
prsb03-dataelement-10884link
The country of birth of the person.NHS data dictionary :- Country code (birth)
treetree draft  Marital status
0 … 1
prsb03-dataelement-10885link
An indicator to identify the legal marital status of the person.NHS data dictionary :- Person marital status
folder About me
0 … 1
prsb03-dataelement-466link
About me
treetree folder What is most important to me
0 … 1
prsb03-dataelement-12964link
A description of what is most important to you.
treeblank treetree draft  What is most important to me
0 … 1
prsb03-dataelement-14325link
A description of what is most important to you 
 Emergency Information : - Include any essential information that any professional in health and social care should know about the you in any situation, including emergencies.
Other Information : -This could include : - Values, Spirituality/religion, Ethnicity, Culture, Pets, Goals and aspirations, Meaningful activities including leisure activities, visiting places, sport and exercise, listening to music, employment, education, volunteeringFree text
treetree folder People who are important to me
0 … 1
prsb03-dataelement-13009link
Details of who is important to you and why. 
treeblank treetree draft  People who are important to me
0 … 1
prsb03-dataelement-14327link
Details of who is important to you and why. They could be family members, carers, friends, members of staff etc. Include how you want the people important to you to be engaged and involved in your care and support in both emergency and normal situations. Include how you stay connected to the people important to you. Who should not be contacted or consulted about your care and support and why, if you wish to sayFree text 
treetree folder How I communicate and how to communicate with me
0 … 1
prsb03-dataelement-13006link
A description of how you communicate normally. 
treeblank treetree draft  How I communicate and how to communicate with me
0 … 1
prsb03-dataelement-14329link

A description of how you communicate normally including any communication aids you use, for example a hearing aid.

  • Include your preferred language of communication, if your first language is not English.
  • Include how you would communicate when you are in pain or distress.
  • Include how you communicate choices.
  • Include how you give feedback or raise a concern.
  • Include how you like to receive information

Describe how you would like others to engage and communicate with you, including how you would like to be addressed.

Free text
treetree folder My wellness
0 … 1
prsb03-dataelement-13005link
A description covering what you are able to do, how you engage with others and how you feel on a typical day through to on a day when you are unwell or really unwell.
treeblank treetree draft  My wellness
0 … 1
prsb03-dataelement-14331link

A description covering what you are able to do, how you engage with others and how you feel on a typical day through to on a day when you are unwell or really unwell

  • Include any causes that might result in you becoming unwell and strategies for avoiding or addressing the causes. For example, not drinking enough water could cause constipation.
  • Include any signs that indicate you might be becoming unwell.
  • On a bad day describe what is different about what you are able to do, how you engage with others and how you feel.
  • Include how your everyday life is affected by any medical conditions e.g. dementia and any symptoms e.g. itchiness, cough, pain and how you manage those conditions.
  • Include past health issues or experiences that need to be considered
  • Include your wellbeing and lifestyle goals and aspirations
    Free text
    treetree folder Please do and please don't
    		0 … 1
    prsb03-dataelement-13008link
    A description of things you want someone supporting you to do (or not to do). 
    treeblank treetree draft  Please do and please don't
    		0 … 1
    prsb03-dataelement-14333link
    A description of things you want someone supporting you to do (or not to do).
    Things you want someone to do might include (for example): - Talk to me not to my carer, remind me to take my medication, encourage me to wash my hands regularly, explain to me what is happening and why, respond to my communication.
    A description of things you do not want someone supporting you to do might include (for example): - Discussing or asking questions about certain topics, making assumptions about something, providing support when it is not wanted, talking to you in a certain way, undergoing a specific intervention or taking a medication the person does not want.Free text
    treetree folder How and when to support me
    		0 … 1
    prsb03-dataelement-13007link
    A description of how and when you want someone caring for you to support you.
    treeblank treetree draft  How and when to support me
    		0 … 1
    prsb03-dataelement-14335link

    A description of how and when you want someone caring for you to support you.

    • This could include support needs in an emergency situation (for example taking blood)
    • This could include support you need to maintain important routines or to carry out particular activities, for example: - Personal care routines, Eating and drinking, Bedtime routines, Taking medications, Moving and transitioning
    • This could also include support needed with:- wearing glasses/hearing aids/false teeth etc, making informed choices or understanding dangers and risks, managing your emotions, moods and behaviours, memory or confusion.
    • Include how your support needs change in different environments. Include any triggers that might result in you needing further support and strategies for avoiding or addressing the triggers. Include how you want the support to be provided.

    Free text
    treetree folder Also worth knowing about me
    		0 … 1
    prsb03-dataelement-13094link
    A description of what is also worth knowing about you for people caring or supporting you. 
    treeblank treetree draft  Also worth knowing about me
    		0 … 1
    prsb03-dataelement-14337link

    A description of what is also worth knowing about you for people caring or supporting you.

    • This could include a short history of your life (where you have worked, where you lived, important events in your life, important people in your past life).
    • This could include a short profile of your current life:- your work / study, your aspirations, your skills, your networks, things you like e.g. particular foods, places, a football team and things you like to talk about, things you dislike
    • This could also include any care and support preferences that have not been included elsewhere.

    Free text
    treetree draft  Supported to write this by
    		0 … 1
    prsb03-dataelement-10368link
    Where relevant, this is a record of name, relationship/role and contact details of the individual who supported the person to write this section e.g. carer, family member, advocate, professional.Free text
    treetree draft  Location to multimedia file
    		0 … 1
    prsb03-dataelement-14326link
    The link to the person's multimedia fileLink to URL
    folder Individual requirements
    		0 … *
    prsb03-dataelement-160link
    The individual requirements of the person.
    treetree folder Reasonable adjustment
    		0 … 1
    prsb03-dataelement-12991link
    A record of reasonable adjustments that must be provided by the service to comply with the Equality Act 2010.
    treetree folder Impairment
    		0 … 1
    prsb03-dataelement-13001link
    A record of any impairments for the person relating to reasonable adjustments.
    treeblank treetree folder Impairment record entry
    		0 … 1
    prsb03-dataelement-13062link
    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
    treeblank treeblank treetree folder Impairment category
    		0 … 1
    prsb03-dataelement-13022link
    The category of the impairment e.g.  Physical disability, Sensory disability - such as sight or hearing, Long-term condition.
    treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-13507link
    The coded value for impairment.SNOMED CT
    treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-13508link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treetree draft  Impairment additional detail
    		0 … 1
    prsb03-dataelement-13023link

    Description of what the person can do with the impairment, what they want to be able to do and how they should be supported to do it and what the consequences are of not providing the support.
    Where there is a sensory disability include sensory processing difficulties (e.g. affects to balance and movement, oversensitive, under-sensitive).
    Free text
    treetree folder Cognition
    		0 … 1
    prsb03-dataelement-10066link
    Details of the persons cognitive impairment.
    treeblank treetree draft  Cognition
    		0 … 1
    prsb03-dataelement-13669link
    The cognitive impairment to be considered when communicating with the person, child or their primary carer.Free text
    treetree folder Mobility
    		0 … 1
    prsb03-dataelement-10067link
    Details of the person's mobility needs.
    treeblank treetree folder Mobility needs
    		0 … 1
    prsb03-dataelement-13670link
    The mobility needs of the person that allows movement between two spaces and achieves participation and a degree of independence.
    treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-13671link
    The coded value for mobility needsSNOMED CT: - ^999002551000000108 |Mobility findings simple reference set (foundation metadata concept)|
    treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-13672link
    Free text field to be used if no code is availableFree text
    treetree folder Other individual requirements
    		0 … 1
    prsb03-dataelement-10835link
    Details of any other individual requirements the person may have.
    treeblank treetree draft  Other individual requirement
    		0 … 1
    prsb03-dataelement-13673link
    Other individual requirements that a person may have.Free text
    folder Alerts
    		0 … *
    prsb03-dataelement-10741link
    Details of alerts.
    treetree folder Alerts record entry
    		0 … 1
    prsb03-dataelement-10916link
    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
    treeblank treetree folder Location of alert
    		0 … 1
    prsb03-dataelement-10756link
    The organisation raising the alert.
    treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-13568link
    The coded value of locationNHS data dictionary: - Organisation data service
    treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-13569link
    Free text field to be used if no code is availableFree text
    treeblank treetree draft  Alert
    		0 … 1
    prsb03-dataelement-10742link
    Any significant information meriting a specific and highly visible warning to any user (e.g. metallic implant, potential dangerous pet).Free text
    folder Legal information
    		0 … 1
    prsb03-dataelement-520link
    The legal information relating to the person.
    treetree folder Consent for treatment record
    		0 … 1
    prsb03-dataelement-10420link
    Details of the person's consent for treatment.
    treeblank treetree draft  Consent for treatment record
    		0 … 1
    prsb03-dataelement-13574link
    Whether consent has been obtained for the treatment. May include where record of consent is located or record of consent. A statement about the patient's consent for treatment.Free text
    treeblank treetree draft  Location of document
    		0 … 1
    prsb03-dataelement-13777link
    The location of the consent for treatment record.Free text or URL
    treetree folder Consent for information sharing
    		1 … 1
    prsb03-dataelement-10421link
    Details of the person's consent for information sharing.
    treeblank treetree draft  Consent for information sharing
    		1 … 1
    prsb03-dataelement-13575link
    This is a record of consent for information sharing under the common law duty of confidentiality. Where consent has not been obtained or sought, the reason why should be provided. Include best interests decision where person lacks capacity. This is a placeholder until the national guidance is published.Free text
    treeblank treetree draft  Reason for consent not given
    		0 … 1
    prsb03-dataelement-13778link
    Reason not given for consentFree text
    treetree folder Consent relating to child
    		0 … 1
    prsb03-dataelement-10422link
    Details of the person's consent relating to child
    treeblank treetree draft  Consent relating to child
    		0 … 1
    prsb03-dataelement-13576link
    The person with parental responsibility or appointed guardian where a child lacks competency. Consideration of age and competency, applying Gillick competency or Fraser guidelines.Free text
    treeblank treetree draft  Location of document
    		0 … 1
    prsb03-dataelement-22489link
    The location of the consent document Free text or URL
    treetree folder Mental capacity assessment
    		0 … 1
    prsb03-dataelement-10424link
    Details of the persons mental capacity assessment
    treeblank treetree draft  Mental capacity assessment
    		0 … 1
    prsb03-dataelement-13724link
    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.Free text
    treeblank treetree draft  Location of document
    		0 … 1
    prsb03-dataelement-13779link
    The location of the mental capacity assessment information.Free text or URL
    treetree folder Lasting power of attorney for health and welfare or court-appointed deputy (or equivalent)
    		0 … *
    prsb03-dataelement-10425link
    Details of the person's LPA record or equivalent
    treeblank treetree folder Lasting power of attorney for health and welfare or court appointed deputy (or equivalent)
    		0 … 1
    prsb03-dataelement-13634link
    Record of one or more people who have been given power (LPA) by the person when they had capacity to make decisions about their health and welfare should they lose capacity to make those decisions. To be valid, an LPA must have been registered with the Court of Protection. If life-sustaining treatment is being considered the LPA document must state specifically that the attorney has been given power to consent to or refuse life-sustaining treatment. Details of any person (deputy) appointed by the court to make decisions about the person’s health and welfare. A deputy does not have the power to refuse life-sustaining treatment.
    treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-13636link
    The coded value for the LPASNOMED CT: - ^999001951000000107 |Personal welfare lasting power of attorney findings simple reference set (foundation metadata concept)|
    treeblank treeblank treetree draft  Location of document
    		0 … 1
    prsb03-dataelement-13776link
    The location of the LPA informationFree text or URL
    treeblank treeblank treetree draft  Name of LPA
    		0 … 1
    prsb03-dataelement-13635link
    The names of any appointed people or deputiesFree text
    treeblank treeblank treetree draft  Contact details
    		0 … 1
    prsb03-dataelement-13637link
    The contact details of the LPANHS data dictionary:- UK telephone number
    treetree folder Lasting power of attorney for property and financial affairs or court-appointed deputy (or equivalent)
    		0 … *
    prsb03-dataelement-14949link
    Details of the person's LPA record or equivalent
    treeblank treetree folder Lasting power of attorney for property and financial affairs or court appointed deputy (or equivalent)
    		0 … *
    prsb03-dataelement-14954link
    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’s property and financial affairs. A deputy does not have the power to refuse life-sustaining treatment.
    treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-14955link
    The coded value for the LPASNOMED CT: - 341041000000103 | Lasting power of attorney property and affairs (observable entity) |
    treeblank treeblank treetree draft  Location of document
    		0 … 1
    prsb03-dataelement-14956link
    The location of the LPA informationFree text or URL
    treeblank treeblank treetree draft  Name of LPA
    		0 … 1
    prsb03-dataelement-14957link
    The names of any appointed people or deputiesFree text
    treeblank treeblank treetree draft  Contact details
    		0 … 1
    prsb03-dataelement-14958link
    The contact details of the LPANHS data dictionary:- UK telephone number
    treetree folder Deprivation of Liberty Safeguards or equivalent
    		0 … 1
    prsb03-dataelement-10426link
    Details of the person's Deprivation of Liberty Safeguards (DoLS) or equivalent
    treeblank treetree draft  Application date
    		0 … 1
    prsb03-dataelement-13068link
    The date the application was madeDate and time
    treeblank treetree draft  Application status
    		0 … 1
    prsb03-dataelement-13069link
    The status of the DOLs application.Free text : - Requested or authorised
    treeblank treetree draft  Deprivation of liberty safeguards or equivalent
    		0 … 1
    prsb03-dataelement-13626link
    Record of Deprivation of Liberty Safeguards (DoLS) or equivalent, including the reason for this.Free text
    treeblank treetree draft  Start date of authorisation
    		0 … 1
    prsb03-dataelement-13071link
    The date the DOLs was authorised.Data and time
    treeblank treetree draft  Planned or actual end date of authorisation
    		0 … 1
    prsb03-dataelement-13072link
    The planned or actual end date of authorisation.Date and time
    treetree folder Mental health act or equivalent status
    		0 … 1
    prsb03-dataelement-10427link
    Details of the persons mental health act record
    treeblank treetree draft  Section start date
    		0 … 1
    prsb03-dataelement-10920link
    The date the person was detained.Date and time
    treeblank treetree draft  Section end date
    		0 … 1
    prsb03-dataelement-10921link
    The date the person was no longer detained.Date and time
    treeblank treetree folder Mental health act or equivalent status
    		0 … 1
    prsb03-dataelement-13627link
    Record where a person diagnosed with a mental disorder is formally detained under the Mental health act or equivalent, including the section number. If person subject to Community Treatment Order or Conditional Discharge (or equivalent) record here.
    treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-13628link
    The coded value for mental health actNHS data dictionary: - Mental health act legal status classification code
    treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-13629link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treetree draft  Supporting information
    		0 … 1
    prsb03-dataelement-13755link
    If person subject to Community Treatment Order or Conditional Discharge (or equivalent) record here.NHS data dictionary : - Community treatment order
    treetree folder Advance decision to refuse treatment (ADRT)
    		0 … 1
    prsb03-dataelement-10428link
    Details of the person's ADRT status.
    treeblank treetree folder Advance decision to refuse treatment
    		0 … 1
    prsb03-dataelement-13502link
    A record of an advance decision to refuse one or more specific types of future treatment, made by a person who had capacity at the time of recording the decision. The decision only applies when the person no longer has the capacity to consent to or refuse the specific treatment being considered. An ADRT must be in writing, signed and witnessed. If the ADRT is refusing life-sustaining treatment it must state specifically that the treatment is refused even if the person’s life is at risk.
    treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-13503link
    The coded value for advance decision to refuse treatment.SNOMED CT:- ^999002181000000105 |Advance decision to refuse treatment preference findings simple reference set (foundation metadata concept)|
    treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-13504link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treetree draft  Location of document
    		0 … 1
    prsb03-dataelement-22480link
    Location of the advance decision to refuse treatment document  Free text or URL
    treetree draft  Advance decision to refuse treatment (ADRT)
    		0 … 1
    prsb03-dataelement-12488link
    A record of whether an advance decision to refuse one or more specific types of future treatment, exists or not.
    The decision only applies when the person no longer has the capacity to consent to or refuse the specific treatment being considered.
    An ADRT must be in writing, signed and witnessed.
    If the ADRT is refusing life-sustaining treatment it must state specifically that the treatment is refused even if the person’s life is at risk. Yes/ No No further information should be sent as anything that is sent must be actionable and therefore must be completely unimpeachable.Where the response is yes, use the SNOMED CT concepts from the National Information Standard (SCCI1580) and associated text: 816301000000100 | Has advance decision to refuse treatment (Mental Capacity Act 2005) (finding) 816321000000109 | Has advance decision to refuse life sustaining treatment (Mental Capacity Act 2005) (finding) 820621000000107 | Has involved healthcare professional in discussion about advance decision to refuse treatment (Mental Capacity Act 2005) (finding)
    treetree draft  Safeguarding issues
    		0 … 1
    prsb03-dataelement-10429link
    Any legal matters relating to safeguarding of a vulnerable child or adult, e.g., child protection plan, protection of vulnerable adult.Information obtained locally, Free Text.
    treetree draft  Parental responsibility
    		0 … 1
    prsb03-dataelement-10423link
    For children this is a record of person(s) with parental responsibilityThis is a record of the name as volunteered by the parents or recorded on local systems. The contact information for these individuals should be included under the relevant contacts heading.
    treetree draft  Consent for creation of end of life care plan
    		0 … 1
    prsb03-dataelement-10431link
    Separate explicit consent is required for creation of an end of life care record. This records how this consent has been granted in order to differentiate between person’s explicit consent, best interest decision, Lasting Power of Attorney decision and withdrawal of consent.End of life care plan use case only. This is a record of consent to create an end of life care plan.
    folder Safeguarding
    		0 … 1
    prsb03-dataelement-271link
    The safeguarding details of the person.
    treetree folder Safeguarding concerns
    		0 … 1
    prsb03-dataelement-10821link
    Details of safeguarding concerns.
    treeblank treetree draft  Safeguarding indicator
    		0 … 1
    prsb03-dataelement-13428link
    Indicates whether or not the hospital considers that there are safeguarding issues associated with the patient.Flag: No =N: Yes = Y
    treeblank treetree draft  Safeguarding concerns date
    		0 … 1
    prsb03-dataelement-10172link
    The date the safeguarding concerns were identified.Date and time
    treeblank treetree draft  Safeguarding concerns end date
    		0 … 1
    prsb03-dataelement-10766link
    The date safeguarding concerns ended.Date and time
    treeblank treetree folder Safeguarding concerns
    		0 … 1
    prsb03-dataelement-10171link
    Identified safeguarding concerns.
    treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-13756link
    The coded value for safeguarding concernsSNOMED CT : - ^999002381000000108 | Safeguarding issues simple reference set (foundation metadata concept) |
    treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-13757link
    Free text field to be used if no code is availableFree text
    treeblank treetree draft  Comment
    		0 … 1
    prsb03-dataelement-10175link
    Further details on safeguarding concerns.Free text
    treetree folder Looked after child
    		0 … 1
    prsb03-dataelement-10797link
    Details of the looked after child.
    treeblank treetree draft  Looked after child start date
    		0 … 1
    prsb03-dataelement-10746link
    The date the child became a looked after child.Date and time
    treeblank treetree draft  Looked after child end date
    		0 … 1
    prsb03-dataelement-10761link
    The date the child ceased to be a looked after child.Date and time
    treeblank treetree folder Local authority
    		0 … 1
    prsb03-dataelement-10799link
    The named local authority.
    treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-13614link
    The coded value for local authorityNHS data dictionary : - Organisation data service
    treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-13615link
    Free text field to be used if no code is availableFree text
    treetree folder Child protection plan
    		0 … 1
    prsb03-dataelement-10798link
    Details of the child protection plan
    treeblank treetree draft  Child protection plan start date
    		0 … 1
    prsb03-dataelement-10747link
    The start date of the child protection planDate and time
    treeblank treetree draft  Child protection plan end date
    		0 … 1
    prsb03-dataelement-10762link
    The end date of the child protection planDate and time
    treeblank treetree folder Local authority
    		0 … 1
    prsb03-dataelement-10748link
    The named local authority.
    treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-13616link
    The coded value for a local authorityNHS data dictionary : - organisation data service
    treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-13617link
    Free text field to be used if no code is availableFree text
    treetree folder Unborn child protection plan
    		0 … 1
    prsb03-dataelement-10923link
    Details of the unborn child protection plan.
    treeblank treetree draft  Unborn child protection plan start date
    		0 … 1
    prsb03-dataelement-10924link
    Start date of the unborn child protection plan.Date and time
    treeblank treetree draft  Unborn child protection plan end date
    		0 … 1
    prsb03-dataelement-10925link
    End date of the unborn child protection plan.Date and time
    treeblank treetree folder Local authority
    		0 … 1
    prsb03-dataelement-10926link
    The named local authority.
    treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-13618link
    The coded value for local authorityNHS data dictionary: - Organisation data service
    treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-13619link
    Free text field to be used if no code is availableFree text
    folder Risks
    		0 … *
    prsb03-dataelement-276link
    Details of any risks related to the person.
    treetree folder Risks record entry
    		0 … 1
    prsb03-dataelement-14460link
    This is a risks record entry. There may be 0 to many record entry/entries under a section. Each record entry is made up of a number of elements or data items.
    treeblank treetree draft  Start date of risk
    		0 … 1
    prsb03-dataelement-14461link
    The start date of the risk.Date and time
    treeblank treetree draft  End date of risk
    		0 … 1
    prsb03-dataelement-14462link
    The date the risk ended.Date and time
    treeblank treetree folder Risk
    		0 … 1
    prsb03-dataelement-14463link
    The risk to the person or others, this includes any risk the person might cause to themselves or to others. e.g. suicide, self harm. 
    treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-21900link
    The coded value for risk.  SNOMED CT: - <281694009 |Finding of at risk (finding)|  
    treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-21899link
    Free text field to be used if no code is available.Free text.
    treeblank treetree draft  Comment
    		0 … 1
    prsb03-dataelement-14485link
    Additional details about the risk. Free text
    draft rotate Circle of Care
    prsb03-transaction-439link
    Version / effective date 2022‑11‑02 11:36:48    
    Actor
    stationary (person) Person
    Associations
    Contained concepts
    Concept Card/Conf Id
    folder Circle of Care
    		1 … 1
    prsb03-dataelement-23125link

    In progress
    treetree folder Professional contacts
    		1 … 1
    prsb03-dataelement-23133link
    The details of the person’s professional contacts.
    treeblank treetree folder Professional contacts record entry
    		0 … *
    prsb03-dataelement-23134link
    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.
    treeblank treeblank treetree draft  Name
    		0 … 1
    prsb03-dataelement-23135link
    The name of the professional with responsibility for the care of the person.Free text
    treeblank treeblank treetree draft  Role
    		0 … 1
    prsb03-dataelement-23136link
    The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker, key worker, care home manager, care coordinator, LA hospital liaison person, care home contact, hospital clinician, Independent Mental Capacity Advocate (IMCA) etcFHIR values set : - ukcorepractitionerrolecode
    treeblank treeblank treetree draft  Speciality
    		0 … 1
    prsb03-dataelement-23138link
    The specialty of the professional e.g. physiotherapy, oncology, mental health etcNHS data dictionary : - Activity treatment function code
    treeblank treeblank treetree draft  Team
    		0 … 1
    prsb03-dataelement-23139link
    The name of the team.Free text
    treeblank treeblank treetree folder Organisation
    		0 … 1
    prsb03-dataelement-23140link
    The name of the organisation.
    treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-23141link
    The coded value for locationNHS data dictionary : - Organisation data service
    treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-23142link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treetree draft  Service
    		0 … 1
    prsb03-dataelement-23143link
    The service that was provided.SNOMED CT :- 1127531000000102 |Services simple reference set (foundation metadata concept)|
    treeblank treeblank treetree draft  Contact details
    		1 … 1
    prsb03-dataelement-23147link
    Contact details of the professional (e.g. telephone number, email address etc.).Free text
    treeblank treeblank treetree draft  Start date
    		1 … 1
    prsb03-dataelement-23148link
    The start date of the professional relationship with the person.Date and time
    treeblank treeblank treetree draft  End date
    		1 … 1
    prsb03-dataelement-23149link
    The end date of the professional relationship with the person.Date and time
    treetree folder Personal contacts
    		0 … 1
    prsb03-dataelement-23159link
    The details of the individual's personal contacts.
    treeblank treetree folder Personal contacts record entry
    		0 … 1
    prsb03-dataelement-23160link
    This is personal contacts record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
    treeblank treeblank treetree draft  Name
    		0 … 1
    prsb03-dataelement-23161link
    The name of the personal contact.Free text
    treeblank treeblank treetree draft  Relationship
    		0 … 1
    prsb03-dataelement-23162link
    The relationship the personal contact has to the person, e.g. father, grandmother, family friend etc.FHIR value set : - Related person
    treeblank treeblank treetree draft  Relationship type
    		0 … 1
    prsb03-dataelement-23163link
    Additional roles the person performs on behalf of the other (e.g. Carer, Next of Kin, Emergency Contact, Dependent, etc.)Free text
    treeblank treeblank treetree draft  Parental Responsibility
    		0 … 1
    prsb03-dataelement-23164link
    Flag to indicate whether the personal contact has parental responsibilityFlag ; - Yes or No
    treeblank treeblank treetree draft  Household member
    		0 … 1
    prsb03-dataelement-23165link
    Status identifying whether the personal contact is a member of the same householdFlag : - Yes or No
    treeblank treeblank treetree draft  Next of Kin
    		0 … 1
    prsb03-dataelement-23166link
    A flag that identifies the personal contact is the next of kinFlag : - Yes or No
    treeblank treeblank treetree draft  Contact details
    		0 … 1
    prsb03-dataelement-23167link
    Contact details of the personal contact (e.g. telephone number, address, email address etc.)Free Text
    treetree folder GP practice
    		1 … 1
    prsb03-dataelement-23179link

    Details of the person's GP practice.
    treeblank treetree folder GP practice record entry
    		0 … *
    prsb03-dataelement-23180link
    This is an GP practice record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items
    treeblank treeblank treetree draft  GP name
    		0 … 1
    prsb03-dataelement-23181link
    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.Free text
    treeblank treeblank treetree draft  GP practice details
    		0 … 1
    prsb03-dataelement-23182link
    Name and address of the person's registered GP Practice. Registered GP practice details are available from the Person Dempographics Service (PDS), or volunteered from the person or their representative. Include details of the practice name and address.Free text
    treeblank treeblank treetree draft  GP practice identifier
    		1 … 1
    prsb03-dataelement-23183link
    The identifier of the registered GP practice. NHS data dictionary : - General medical practice code (patient registration)
    draft rotate General Health Information and Relevant History
    prsb03-transaction-435link
    Version / effective date 2022‑10‑31 15:06:52    
    Description

    The general health information and relevant history is the view of the a person's record in the EPR/shared carer record that a health care professional requires access to in order to deliver safe and effective care.

    Associations
    Contained concepts
    Concept Card/Conf Id
    folder Relevant past medical, surgical and mental health history
    		0 … *
    prsb03-dataelement-547link
    The record of the person’s significant medical, surgical and mental health history. Including relevant previous diagnoses, problems and issues, procedures, investigations, specific anaesthesia issues, etc (with obstetric history).
    treetree draft  Gynaecology
    		0 … *
    prsb03-dataelement-10450link
    A record of the woman’s gynaecology medical history relevant to the maternity episode, including relevant previous diagnoses, problems and issues, procedures, surgeries and investigations.
    treetree draft  Past obstetric
    		0 … *
    prsb03-dataelement-10451link
    A record of the woman’s obstetric medical history relevant to the maternity episode. To include each previous pregnancy details and the outcome.
    treetree draft  Relevant past medical history
    		0 … *
    prsb03-dataelement-10452link
    The record of the person's significant medical, history. Including relevant previous diagnoses, health history problems and issues.
    treetree draft  Relevant past surgical history
    		0 … *
    prsb03-dataelement-10453link
    The record of the person’s significant surgical history. Including relevant issues, procedures, investigations, specific anaesthesia issues, etc.
    treetree draft  Relevant past mental health history
    		0 … *
    prsb03-dataelement-10454link
    A record of the person’s mental health history relevant to the episode
    treetree draft  Acute Hospital Episodes
    		0 … *
    prsb03-dataelement-10455link
    Reported details of any history of acute hospital episodes including ITU, HDU and A&E attendances the woman has had.
    treetree draft  Mental Health Admissions
    		0 … *
    prsb03-dataelement-10456link
    Reported details of any history of mental health admissions.
    treetree draft  Relevant past medical, surgical and mental health history
    		0 … *
    prsb03-dataelement-12476link
    The record of the person's significant medical, surgical and mental health history (will include dental and obstetric history). Including relevant previous diagnoses, problems and issues, procedures, investigations, specific anaesthesia issues, etc.A list of the person's relevant past medical, surgical and mental health history recorded in free text or coded form.
    folder Problem list
    		0 … *
    prsb03-dataelement-10927link
    A summary of the problems that require investigation or treatment.
    treetree folder Problem list record entry
    		0 … 1
    prsb03-dataelement-10928link
    This is a problem list record entry.

    There may be 0 to many record entries under problem list.

    Each record entry is made up of a number of elements or data items.
    treeblank treetree folder Problem
    		0 … 1
    prsb03-dataelement-10932link
    A condition which needs addressing and so is important for every professional to know about when seeing the person.

    Problems may include diagnoses, symptoms, and social or behavioural issues
    treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-13244link
    The coded value for the problem list.SNOMED CT : - ^1127581000000103 |Health issues simple reference set|
    treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-13245link
    Free text field to be used if no code is availableFree text
    treeblank treetree draft  Onset date
    		0 … 1
    prsb03-dataelement-10933link
    A date or estimated date that the problem beganDate and time
    treeblank treetree draft  End Date
    		0 … 1
    prsb03-dataelement-10934link
    The date or estimated date the problem was resolved.Date and time.
    treeblank treetree folder Severity
    		0 … 1
    prsb03-dataelement-18208link
    The severity of the problem. 
    treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-18209link
    The coded value for severity. SNOMED CT.
    treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-18210link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Body site
    		0 … 1
    prsb03-dataelement-18211link
    The body site relevant to the problem.
    treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-18212link
    The coded value for body site. SNOMED CT.
    treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-18213link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Laterality
    		0 … 1
    prsb03-dataelement-18214link
    The laterality of the problem (left or right).
    treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-18215link
    The coded value for laterality.SNOMED CT.
    treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-18216link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Stage of disease
    		0 … 1
    prsb03-dataelement-18217link
    The stage of the disease where relevant.
    treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-18218link
    The coded value for stage of disease.SNOMED CT.
    treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-18219link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Problem status
    		0 … 1
    prsb03-dataelement-18220link
    The status of the problem. This can be either active or inactive.
    treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-18221link
    The coded value for problem status.SNOMED CT.
    treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-18222link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Problem priority
    		0 … 1
    prsb03-dataelement-18223link
    The problem priority level. This can be either significant or minor. 
    treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-18224link
    The coded value for problem priority. SNOMED CT.
    treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-18225link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Problem on discharge
    		0 … 1
    prsb03-dataelement-14262link
    The main problem or diagnosis on discharge.

    Problems may include diagnoses, symptoms, disabilities and social or behavioural issues, and comprise the ‘Problem list’
    treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-14263link
    The coded value for the problem list.SNOMED CT : - ^1127581000000103 |Health issues simple reference set|
    treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-14264link
    Free text field to be used if no code is availableFree text
    folder Procedures and therapies
    		0 … *
    prsb03-dataelement-238link
    The details of any procedures performed. Includes both psychological and medical therapies and procedures (e.g. cognitive behaviour therapy, hip replacement)
    treetree folder Procedure record entry
    		0 … 1
    prsb03-dataelement-10652link
    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.
    treeblank treetree folder Procedure
    		0 … 1
    prsb03-dataelement-10141link
    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.
    treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-13249link
    The procedure code.SNOMED CT : - <<71388002 |Procedure| OR <<129125009 |Procedure with explicit context|
    treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-13250link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Anatomical site
    		0 … 1
    prsb03-dataelement-10142link
    The body site of the procedure
    treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-13251link
    The coded value of the anatomical site.SNOMED CT :- <123037004 |Body structure (body structure)|
    treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-13252link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Laterality
    		0 … 1
    prsb03-dataelement-10143link
    Laterality of the procedure
    treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-13253link
    The coded value for laterality.SNOMED CT:- <182353008 |Side (qualifier value)|
    treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-13254link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Complications related to procedure
    		0 … 1
    prsb03-dataelement-10144link
    Details of any intra-operative complications encountered during the procedure, arising during the person’s stay in the recovery unit or directly attributable to the procedure.
    treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-13255link
    The coded value for complications relating to procedure.SNOMED CT : - <404684003 |Clinical finding (finding)|
    treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-13256link
    Free text field to be used if no code is availableFree text
    folder Social context
    		0 … *
    prsb03-dataelement-136link
    The social setting in which the person lives, such as their household, occupational history, and lifestyle factors.
    treetree draft  Services and care
    		0 … *
    prsb03-dataelement-12482link
    The description of services and care providing support for person's health and social well-being.Free text. The record of the services and care as provided by the person or their representative.
    treetree folder Household composition
    		0 … 1
    prsb03-dataelement-10036link
    Details of the person's household composition.
    treeblank treetree folder Household composition
    		0 … 1
    prsb03-dataelement-13261link
    Description of the household composition e.g. lives alone, lives with family, lives with partner, shared accommodation etc.
    treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-13262link
    The coded value of household compositionSNOMED CT: - 1027891000000106 | Household composition findings simple reference set (foundation metadata concept) |
    treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-13263link
    Free text field to be used if no code is availableFree text
    treetree folder Occupational history
    		0 … *
    prsb03-dataelement-10037link
    The current and/or previous occupation(s) of the person.
    treeblank treetree folder Occupational history
    		0 … 1
    prsb03-dataelement-13264link
    The current and/or previous occupation(s) of the person.
    treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-13265link
    The coded value for occupational historySNOMED CT : - ^999001571000000109 | Occupation simple reference set (foundation metadata concept)
    treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-13266link
    Free text field to be used if no code is availableFree text
    treetree folder Driving status
    		0 … 1
    prsb03-dataelement-18226link
    The driving status of the person.
    treeblank treetree folder Current driver
    		0 … 1
    prsb03-dataelement-18231link
    Details of whether the person currently drives or not. 
    treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-18232link
    The coded value for current driver.SNOMED CT.
    treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-18233link
    Free text field to be used if no code is availableFree text
    treetree folder Educational history
    		0 … 1
    prsb03-dataelement-10038link
    Details of the person's educational history.
    treeblank treetree draft  Educational history
    		0 … *
    prsb03-dataelement-13840link
    The current and/or previous relevant educational history of the person.Free text
    treetree folder Lifestyle choices
    		1 … 1
    prsb03-dataelement-10039link
    The lifestyle choices made by the person which are pertinent to his or her health and well-being, e.g. physical activity level, pets, hobbies and sexual habits
    treeblank treetree draft  Lifestyle choices
    		0 … *
    prsb03-dataelement-13841link
    The lifestyle choices made by the person which are pertinent to his or her health and well-being, e.g. physical activity level, pets, hobbies and sexual preferences.Free text
    treetree folder Nutrition
    		0 … 1
    prsb03-dataelement-22674link
    Details of the person's nutrition. 
    treeblank treetree folder Meal patterns
    		0 … *
    prsb03-dataelement-22675link
    Latest or current meal patterns. 
    treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-22677link
    The coded value for meal patterns. SNOMED CT.
    treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-22676link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Nutritional findings
    		0 … *
    prsb03-dataelement-23130link
    Details of the person's nutritional status and behaviours. e.g., excessive or inadequate intake of energy, fat, protein, carbohydrate, salt, foods, fluids, nutrients, vitamins and minerals.
    treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-23131link
    The coded value for nutritional findings.
    SNOMED CT.
    treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-23132link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Nutritional intake
    		0 … *
    prsb03-dataelement-23126link
    Quantifiable details of the person's nutritional intake. e.g., estimated or measured intake of energy, fat, protein, salt, foods, fluids, nutrients, vitamins and minerals.
    treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-23127link
    The coded value for nutritional intake. 
    SNOMED CT.     
    treeblank treeblank treetree draft  Value
    		0 … 1
    prsb03-dataelement-23128link
    The value of nutritional intake. 
    Numeric.
    treeblank treeblank treetree draft  Units of measure
    		0 … 1
    prsb03-dataelement-23129link
    The units of measure for nutritional intake.
    UCUM code.
    treeblank treetree folder Carbohydrate intake
    		0 … *
    prsb03-dataelement-22678link
    Quantifiable details of the person's carbohydrate intake e.g., measured or estimated intake in one meal or over a 24 hour period. 
    treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-22682link
    The coded value for carbohydrate intake.SNOMED CT.     
    treeblank treeblank treetree draft  Value
    		0 … 1
    prsb03-dataelement-22683link
    The value of carbohydrate intake.Numeric.
    treeblank treeblank treetree draft  Units of measure
    		0 … 1
    prsb03-dataelement-22684link
    The units of measure for carbohydrate intake.
    UCUM code.
    treetree folder Smoking status
    		0 … 1
    prsb03-dataelement-10040link
    Details of the person's smoking status.
    treeblank treetree folder Smoking status
    		0 … 1
    prsb03-dataelement-13283link
    Record of any smoking use by the person.
    treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-13284link
    The smoking status of the person.SNOMED CT:- ^999000891000000102 |Smoking simple reference set (foundation metadata concept)|
    treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-13285link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Smoking record
    		0 … 1
    prsb03-dataelement-13995link
    Details of the person's smoking record
    treeblank treeblank treetree draft  Overall smoking status
    		0 … 1
    prsb03-dataelement-13996link

    Statement about current smoking behaviour for smoking cigarettes (manufactured or roll up).

    Defined by current smoking status and ever smoking status.

    Coded text: Current Smoker Former Smoker Never Smoked ^999000891000000102 |Smoking simple reference set (foundation metadata concept)|
    treeblank treeblank treetree draft  Date of quitting
    		0 … 1
    prsb03-dataelement-13997link
    Date when the individual stopped smoking (if a former smoker).Date and time
    treeblank treeblank treetree draft  Other tobacco products used
    		0 … 1
    prsb03-dataelement-13998link
    Details of other tobacco products used (e.g. shisha, pipe, cigar, heated tobacco products) No other tobacco products used Patient uses other tobacco products. Plus free text details of products used.
    treeblank treeblank treetree draft  Information and advice given
    		0 … 1
    prsb03-dataelement-13999link
    Record of whether brief advice about available smoking cessation treatment/support was given at the time of consultation. No advice given about available smoking cessation treatment/support Brief advice given about available smoking cessation treatment/support Plus free text with any additional information
    treeblank treeblank treetree draft  Nicotine Replacement Therapy used
    		0 … 1
    prsb03-dataelement-14000link
    A record of whether nicotine replacement therapy (NRT) is currently used or prescribed in this appointment NRT not currently used NRT currently used NRT prescribed at this appointment
    treeblank treeblank treetree draft  Varenicline or other pharmacotherapy used
    		0 … 1
    prsb03-dataelement-14001link
    Record of whether varenicline or other smoking cessation pharmacotherapy (other than nicotine replacement therapy) is currently used or prescribed in this appointment. Varenicline/other pharmacotherapy not used Varenicline/other pharmacotherapy currently used Varenicline/other pharmacotherapy prescribed in this appointment
    treeblank treeblank treetree draft  e-cigarettes used
    		0 … 1
    prsb03-dataelement-14002link
    Record of current use of e-cigarettes Coded - SNOMED CT: 722499006 |Electronic cigarette user (finding)|
    treeblank treeblank treetree draft  Therapy prescribed (see medication item entry information model)
    		0 … 1
    prsb03-dataelement-14003link
    Record of nicotine replacement therapy, varenicline or bupropion (or other smoking cessation pharmacotherapy) being prescribed at the time of the consultationTo be entered via Medication item entry (see medications and medical devices information model - PRSB Standards for the Structure and Content of Health and Care Records (2018): https://theprsb.org/standards/healthandcarerecords/
    treeblank treeblank treetree draft  Referral details
    		0 … 1
    prsb03-dataelement-14004link
    Record of whether referral to smoking cessation services was offered and/or made at the time of the consultation. Referral to smoking cessation services Referral not offered Referral offered but declined And free text with any additional information
    treetree folder Alcohol intake
    		0 … 1
    prsb03-dataelement-10041link
    Details of the person's alcohol intake
    treeblank treetree folder Alcohol intake
    		0 … 1
    prsb03-dataelement-13290link
    Latest or current alcohol consumption.
    treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-13291link
    The coded value of the person alcohol intakeSNOMED CT :- 219006 |Current drinker of alcohol (finding)| OR 105542008 |Current non-drinker of alcohol (finding)| OR 228274009 |Lifetime non-drinker (finding)| OR 1104551000000109 |Declined to provide information about alcohol use (situation)| OR 371434005 |History of alcohol abuse (situation)|
    treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-13292link
    Free text field to be used if no code is availableFree text
    treetree folder Drug/substance use
    		0 … *
    prsb03-dataelement-10042link
    Details of the person's drug and substance use.
    treeblank treetree folder Drug/substance use
    		0 … 1
    prsb03-dataelement-13336link
    Latest or current drug/substance use.
    treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-13337link
    The coded value for drug and substance misuse.SNOMED CT:- 361055000 |Misuses drugs (finding)| OR 371422002 |History of substance abuse (situation)| OR 228368007 |Has never misused drugs (situation)| OR 783241000000102 |Declined to give substance misuse history (finding)|
    treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-13338link
    Free text field to be used if no code is availableFree text
    treetree folder Social circumstances
    		0 … *
    prsb03-dataelement-10043link
    Details of the persons social circumstances
    treeblank treetree draft  Social circumstances
    		0 … 1
    prsb03-dataelement-13341link
    A person’s social background, network and personal circumstances, e.g. housing. This should include whether the person is a carer.Free text
    treetree folder Access
    		0 … *
    prsb03-dataelement-10045link
    Details of access for the person.
    treeblank treetree draft  Access
    		0 … 1
    prsb03-dataelement-13342link
    Special access requirements e.g. key safe, coded lock, which door to use, stretcher access, etc.Free text
    treetree folder Dependants
    		0 … *
    prsb03-dataelement-10046link
    Details of any responsibility the person has for dependants.
    treeblank treetree draft  Dependants
    		0 … 1
    prsb03-dataelement-13345link
    Provide details of any responsibility the person has for dependants. In the case of children provide date of birth of the child.Free text
    treetree folder Accommodation status
    		0 … *
    prsb03-dataelement-10047link
    Details of the type of accommodation where the person lives.
    treeblank treetree folder Accommodation status
    		0 … 1
    prsb03-dataelement-13348link
    An indication of the type of accommodation where the person lives.

    This should be based on the main or permanent residence.
    treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-13349link
    The coded value for accommodation statusNHS data dictionary :- Accommodation status
    treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-13350link
    Free text field to be used if no code is availableFree text
    treetree folder Household environment
    		0 … *
    prsb03-dataelement-10051link
    Details of the person's household environment.
    treeblank treetree draft  Household environment
    		0 … 1
    prsb03-dataelement-13842link
    Factors in the household which impact the person's health and wellbeing, to include smoking in the home, alcohol/substance use etc.Free text
    folder Investigation results
    		0 … *
    prsb03-dataelement-257link
    Investigation results
    treetree folder Investigation results record entry
    		0 … 1
    prsb03-dataelement-10654link
    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.
    treeblank treetree folder Investigation
    		0 … 1
    prsb03-dataelement-10160link
    The investigation performed.
    treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-13525link
    The coded value for investigationSNOMED CT: - <71388002 |Procedure (procedure)|
    treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-13526link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Investigation result
    		0 … 1
    prsb03-dataelement-10161link
    For each investigation, the result of the investigation. This can include a report which may have results for multiple tests.
    treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-13527link
    The coded value for investigation resultsSNOMED CT:- <404684003 |Clinical finding (finding)| OR <243796009 |Situation with explicit context (situation)|
    treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-13528link
    Free text field to be used if no code is availableFree text
    treeblank treetree draft  Investigation Method
    		0 … 1
    prsb03-dataelement-14094link
    Method used in carrying out investigationCoded entry - Point of care test, Laboratory test
    treeblank treetree folder Structured investigation result
    		0 … 1
    prsb03-dataelement-12415link
    A structured set of information for each investigation result.
    treeblank treeblank treetree draft  Value
    		0 … 1
    prsb03-dataelement-12416link
    The value of the investigation result.Numeric
    treeblank treeblank treetree draft  Units of measure
    		0 … 1
    prsb03-dataelement-12417link
    The units of the investigation result.UCUM code
    treeblank treeblank treetree draft  Reference ranges
    		0 … 1
    prsb03-dataelement-12418link
    The reference range for the investigation result.Free text
    treeblank treeblank treetree draft  Abnormal indicator
    		0 … 1
    prsb03-dataelement-12419link
    Indicator if the investigation is abnormal.Abnormal or Normal
    folder Allergies and adverse reactions
    		0 … *
    prsb03-dataelement-282link
    Allergies and adverse reactions
    treetree folder Allergies and adverse reactions record entry
    		0 … 1
    prsb03-dataelement-10657link
    This is a allergies and adverse reactions record entry. There may be 1 to many record entries under a section.

    Each record entry is made up of a number of elements or data items.
    treeblank treetree draft  Type of reaction
    		0 … 1
    prsb03-dataelement-10186link
    The type of reaction experienced by the person (allergic, adverse, intolerance)FHIR value set :- Allergy, Intolerance
    treeblank treetree folder Causative agent
    		0 … 1
    prsb03-dataelement-10182link
    The agent such as food, drug or substances that has caused or may cause an allergy, intolerance or adverse reaction in this person Or “No known drug allergies or adverse reactions” Or “Information not available”
    treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-13441link
    The coded value for causative agent 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)
    treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-13442link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Reaction details cluster
    		0 … 1
    prsb03-dataelement-10658link
    Details of the reaction.
    treeblank treeblank treetree draft  Date
    		0 … 1
    prsb03-dataelement-10190link
    The date that the reaction was identified.Date and time
    treeblank treeblank treetree folder Substance
    		0 … 1
    prsb03-dataelement-11665link
    The substance, or a class of substances, that is considered to be responsible for the adverse reaction.
    treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-13554link
    The coded value for substanceSNOMED CT : - <105590001 | Substance (substance) | or <373873005 | Pharmaceutical / biologic product (product) |
    treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-13555link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treetree folder Description of reaction
    		0 … 1
    prsb03-dataelement-10183link
    A description of the manifestation of the allergic or adverse reaction experienced by the person. For example, skin rash.
    treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-13556link
    The coded value for description of reaction.SNOMED CT: - ^1127581000000103 |Health issues simple reference set|
    treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-13557link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treetree draft  Onset date
    		0 … 1
    prsb03-dataelement-13844link
    Date and time when manifestations showed e.g could be at home a few days earlier than the contactDate and time
    treeblank treeblank treetree folder Severity
    		0 … 1
    prsb03-dataelement-10184link
    A description of the severity of the reaction.
    treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-13558link
    The coded value for severityFHIR value set : - Severity
    treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-13559link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treetree folder Certainty
    		0 … 1
    prsb03-dataelement-10185link
    A description of the certainty that the stated causative agent caused the allergic or adverse reaction.
    treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-13560link
    The coded value for certainty.FHIR value set : - Certainty
    treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-13561link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treetree folder Route of exposure
    		0 … 1
    prsb03-dataelement-13856link
    The route the person was exposed to the substance
    treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-13857link
    The coded value for route of exposureSNOMED CT: - ^999000051000001100 |ePrescribing route of administration simple reference set|
    treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-13858link
    Free text field to be used if no coded text available Free text 
    treeblank treetree draft  Evidence
    		0 … 1
    prsb03-dataelement-10187link
    Results of investigations that confirmed the certainty of the diagnosis. Examples might include results of skin prick allergy testsFree text
    treeblank treetree draft  Date first experienced
    		0 … 1
    prsb03-dataelement-10188link
    When the reaction was first experienced i.e this may not be the first time this has happened. May be a date or partial date (e.g. year) or text (e.g. during childhood)
    Date and time
    treeblank treetree draft  Allergy end date
    		0 … 1
    prsb03-dataelement-14253link
    The date the allergy was diagnosed as endedDate and time 
    folder Medications and medical devices
    		0 … *
    prsb03-dataelement-636link
    Medications and medical devices
    treetree folder Medication administration record entry
    		0 … 1
    prsb03-dataelement-12483link
    Each entry holds details of medications administered
    treeblank treetree folder Medication name
    		0 … 1
    prsb03-dataelement-12484link
    May be generic name or brand name.
    treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-13663link
    The coded value for medication namedm+d:- any code from the VTM, VMP, AMP, VMPP and AMPP concept classes
    treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-13664link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Method
    		0 … 1
    prsb03-dataelement-18205link
    The technique or method by which the medication is to be administered.
    treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-18206link
    The coded value for methodSNOMED CT : - ^999000041000001103 | ePrescribing method simple reference set (foundation metadata concept) |
    treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-18207link
    Free text field to be used if no coded text available
    treeblank treetree folder Route
    		0 … 1
    prsb03-dataelement-12485link
    The route by which the medication is administered e.g. oral, IM, IV
    treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-13661link
    The coded value for routeSNOMED CT: - ^999000051000001100 |ePrescribing route of administration simple reference set (foundation metadata concept)|
    treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-13662link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Device type
    		0 … 1
    prsb03-dataelement-21033link
    The device type. 
    treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-21034link
    The coded value for device type.SNOMED CT.
    treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-21035link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Dose context
    		0 … 1
    prsb03-dataelement-23072link
    Supporting information about the dose administered e.g., carbohydrate coverage or high blood sugar correction insulin dose.
    treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-18391link
    The coded value for dose context. 
    SNOMED CT.
    treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-23073link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Dose administered
    		0 … 1
    prsb03-dataelement-18390link
    Details of dose administered.
    treeblank treeblank treetree draft  Value
    		0 … 1
    prsb03-dataelement-18392link
    The value for dose administered.Numerical value.
    treeblank treeblank treetree draft  Units of measure
    		0 … 1
    prsb03-dataelement-18393link
    The units of measure for dose administered. UCUM code.
    treeblank treeblank treetree draft  Administration date and time
    		0 … 1
    prsb03-dataelement-20999link
    The date and time when the medication was administered.Date and time
    treeblank treeblank treetree draft  Start date/time
    		0 … 1
    prsb03-dataelement-21014link
    The date and time that the infusion started. Date and time
    treeblank treeblank treetree draft  End date/time
    		0 … 1
    prsb03-dataelement-21015link
    The date and time that the infusion ended.Date and time
    draft rotate Treatment Plan
    prsb03-transaction-436link
    Version / effective date 2022‑10‑31 16:07:24    
    Description

    For most wounds, the overall aim will be healing by primary intention within a specified time frame but there may be some wounds that are allowed to heal by secondary intention and the treatment aim may be wound bed preparation, other intermediate aims which should also be recorded such as reduction in pain, odour etc.

    Associations
    Contained concepts
    Concept Card/Conf Id
    folder Care and support plan
    		0 … 1
    prsb03-dataelement-508link
    This records the decisions reached during conversation between the individual and health and care professional about future plans and also records progress.
    treetree folder Strengths
    		0 … *
    prsb03-dataelement-10419link
    Any strengths and assets the person has relating to their goals and hopes about their health and well-being.
    treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-14369link
    The coded value associated with the person's strengths.  Could be derived from the assessment of the person e.g. 300738008 |Able to participate in leisure activities (finding)|
    SNOMED CT : - 1127601000000107 | Healthcare matters simple reference set (foundation metadata concept) |
    treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-14370link
    The person’s strengths (in free text). If the strengths are coded then this is any supplementary or personalised information that relates to the coded strength. Free text
    treetree folder Needs, concerns or problems
    		0 … *
    prsb03-dataelement-10414link
    Details of the person needs, concerns or problems
    treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-14371link
    The coded value associated with the person's needs, concerns or problems.SNOMED CT : - ^1127581000000103 |Health issues simple reference set|
    treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-14372link
    The person’s needs, concerns or problems (in free text). If the needs, concerns or problems are coded then this is any supplementary or personalised information that relates to the coded need, concern or problem.
    Free text 
    treeblank treetree folder Goals and hopes
    		0 … *
    prsb03-dataelement-10413link
    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.
    treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-14373link
    The coded value associated with the person's goals, aim's and hopes. e.g. 999002111000000103 |Occupational therapy goals simple reference set (foundation metadata concept)|SNOMED CT : - 413350009|Finding with explicit context|: 246090004|Associated finding|=300798006 |Able to participate in sporting activities (finding)|, 408729009|Finding context|=410518001|Goal|
    treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-14374link
    The person’s goals and hopes (in free text). If the goals and hopes are coded then this is any supplementary or personalised information that relates to the coded goal or hope. Free text
    treeblank treeblank treetree draft  Goal importance score
    		0 … 1
    prsb03-dataelement-14399link
    Assessment of the person's motivations to achieve this goal, how important the goal is to the person on a scale of 1-10.Numeric scale 1 - 10
    treeblank treeblank treetree folder Actions and activities
    		0 … *
    prsb03-dataelement-10408link
    Actions or activities the person or others plan to take to achieve the person's goals and the resources required to do this.

    treeblank treeblank treeblank treetree folder What
    		0 … 1
    prsb03-dataelement-10675link
    What the action is and how it is to be carried out?
    treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-14383link
    The coded value for the action.

    SNOMED CT : - <<71388002 |Procedure| OR <<129125009 |Procedure with explicit context|
    treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-14384link
    The person’s actions (in free text). If the actions are coded then this is any supplementary or personalised information that relates to the coded action. Free text
    treeblank treeblank treeblank treetree folder Who
    		0 … 1
    prsb03-dataelement-10676link
    Name and role (e.g. person, carer, GP, OT, etc.) of the person, or a team, carrying out the proposed action, and, if relevant where action should take place.
    treeblank treeblank treeblank treeblank treetree draft  Name
    		0 … 1
    prsb03-dataelement-14393link
    The name of the professional or person carrying out the proposed action.Free text
    treeblank treeblank treeblank treeblank treetree draft  Role
    		0 … 1
    prsb03-dataelement-14394link
    The role of the person providing the service.FHIR values set : - ukcorepractitionerrolecode
    treeblank treeblank treeblank treeblank treetree draft  Team
    		0 … 1
    prsb03-dataelement-14395link
    The name of the team.Free text
    treeblank treeblank treeblank treeblank treetree draft  Contact details
    		0 … 1
    prsb03-dataelement-14396link
    Contact details of the professional (e.g. telephone number, email address etc.).Free text
    treeblank treeblank treeblank treetree draft  When
    		0 … 1
    prsb03-dataelement-10677link
    Planned date, time, or interval, as relevantDate and time
    treeblank treeblank treeblank treetree draft  Suggested strategies
    		0 … 1
    prsb03-dataelement-10678link
    Suggested strategies for potential problems.Free text.
    treeblank treeblank treeblank treetree folder Status
    		0 … 1
    prsb03-dataelement-10679link
    The status of the action or activity e.g. in progress, done, refused
    treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-14385link
    The coded value for the person's activity statusSNOMED CT : - ^999000081000000105 | Care planning action context values simple reference set (foundation metadata concept) |
    treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-14386link
    Any supplementary or personalised information for the person's activity statusFree text
    treeblank treeblank treeblank treetree draft  Confidence
    		0 … 1
    prsb03-dataelement-10680link
    How confident the person feels to carry out the action associated to the goal.Numeric score 1 - 10
    treeblank treeblank treeblank treetree draft  Date last updated
    		0 … 1
    prsb03-dataelement-10682link
    Date when action/activity record was last updatedDate and time
    treeblank treeblank treeblank treetree draft  Review date
    		0 … 1
    prsb03-dataelement-10683link
    When the action evaluation needs to be reviewed. SNOMED CT tag : - 425268008 | Review of care plan (procedure) |Date and time.
    treeblank treeblank treeblank treetree folder Stage goal
    		0 … *
    prsb03-dataelement-10674link
    Details of the person's stage goals
    treeblank treeblank treeblank treeblank treetree folder Stage goal
    		0 … 1
    prsb03-dataelement-14284link
    A specific sub-goal that is related to the overall goal as agreed by the person in collaboration with a professional.
    treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-14375link
    The coded expression associated with the person's stage goal.SNOMED CT : - 413350009|Finding with explicit context|: 246090004|Associated finding|=300798006 |Able to participate in sporting activities (finding)|, 408729009|Finding context|=410518001|Goal|
    treeblank treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-14376link
    The person’s stage goal (in free text). If the stage goal is coded then this is any supplementary or personalised information that relates to the coded stage goal. Free text
    treeblank treeblank treeblank treeblank treetree folder Outcome
    		0 … 1
    prsb03-dataelement-10681link
    The outcome of the stage goal
    treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-14378link
    The coded value for the person's stage goal outcome.SNOMED CT: - ^1127601000000107 |Healthcare matters simple reference set (foundation metadata concept)| 
    treeblank treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-14379link
    Any supplementary and personalised information relating to the person's outcome.Free text
    treeblank treeblank treeblank treeblank treetree draft  Goal status
    		0 … 1
    prsb03-dataelement-14377link
    The status associated with the person's stage goalSNOMED CT: - ^999000091000000107 | Care planning goal context values simple reference set (foundation metadata concept) |
    treeblank treeblank treetree folder Outcomes
    		0 … *
    prsb03-dataelement-10416link
    Outcomes of each of the person’s goals, aims and targets. Includes comments recorded by the person, date and status.
    treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-14380link
    The coded value associated with the person's overall goal outcomeSNOMED CT: - ^1127601000000107 |Healthcare matters simple reference set (foundation metadata concept)| 
    treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-14382link
    The person’s outcome (in free text) of a goal. If the outcome is coded then this is any supplementary or personalised information that relates to the coded outcome.
    Free text
    treeblank treeblank treetree draft  Goal status
    		0 … 1
    prsb03-dataelement-14400link
    The status associated with the person's overall goal.SNOMED CT: - ^999000091000000107 | Care planning goal context values simple reference set (foundation metadata concept) |
    treetree folder Agreed with person or legitimate representative
    		0 … 1
    prsb03-dataelement-10409link
    Indicates whether the plan was discussed and agreed with the person or legitimate representative.
    treeblank treetree draft  Person or legitimate representative
    		0 … 1
    prsb03-dataelement-14322link
    Indicates whether the plan was discussed and agreed with the person or legitimate representativePerson or legitimate representative 
    treeblank treetree draft  Person full name
    		0 … 1
    prsb03-dataelement-14323link
    The full name of the person in text representation.NHS data dictionary :- Person full name
    treeblank treetree draft  Role
    		0 … 1
    prsb03-dataelement-14324link
    The role the professional has in relation to the person.FHIR value set : - sdsjobrole
    treetree folder Care funding source
    		0 … 1
    prsb03-dataelement-10410link
    A reference to the funding source and any conditions or limitations associated.
    treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-14391link
    The organisation code of the care funding sourceNHS data dictionary : - organisation data service
    treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-14392link
    Any further information for the person's care funding source e.g. self fundedFree text 
    treetree draft  Date this plan was last updated
    		0 … 1
    prsb03-dataelement-10412link
    This is a record of the date that this care and support plan was last updated.Date and time
    treetree draft  Other care planning documents
    		0 … *
    prsb03-dataelement-10415link
    Reference other care planning documents, including the type, location and date.

    This may include condition-specific plans, advance care plans, end of life care plan, etc.Free text.
    treetree draft  Planned review date/interval
    		0 … 1
    prsb03-dataelement-10417link
    This is the date/interval when this information will next be reviewed. SNOMED CT tag : - 425268008 | Review of care plan (procedure) |Date and time
    treetree folder Responsibility for review
    		0 … 1
    prsb03-dataelement-10418link
    This is a record of who has responsibility for arranging review of this information.
    treeblank treetree draft  Name
    		0 … 1
    prsb03-dataelement-14345link
    The name of the professional with responsibility for the care of the person.Free text
    treeblank treetree draft  Role
    		0 … 1
    prsb03-dataelement-14346link
    The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker, key worker, care home manager, care coordinator, LA hospital liaison person, care home contact, hospital clinician, Independent Mental Capacity Advocate (IMCA) etcFHIR values set : - ukcorepractitionerrolecode
    treeblank treetree draft  Contact details
    		0 … 1
    prsb03-dataelement-14347link
    Contact details of the professional (e.g. telephone number, email address etc.).Free text
    folder Contingency plans
    		0 … *
    prsb03-dataelement-469link
    These are the things to do and people to contact, should an individual’s health or other circumstances get worse.
    treetree folder Trigger factors
    		1 … *
    prsb03-dataelement-10375link
    Signs to watch out for that may indicate a significant change in health or other circumstances e.g. feeling agitated
    treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-14389link
    The trigger that leads to instigation of a significant change in health or other circumstances.
    SNOMED CT: - ^1127581000000103 | Health issues simple reference set (foundation metadata concept) |
    treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-14390link
    The person’s trigger factors (in free text). If the trigger factor is coded then this is any supplementary or personalised information that relates to the coded trigger factor. Free text
    treetree folder Contingency plan name
    		0 … 1
    prsb03-dataelement-10371link
    When the action evaluation needs to be reviewed. 
    treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-14387link
    The coded value for the type of care planSNOMED CT: - 999001471000000108 | Care plan type simple reference set (foundation metadata concept) |
    treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-14388link
    Free text if no coded value is available.Free text
    treetree folder What should happen
    		0 … *
    prsb03-dataelement-10376link
    Guidance on specific actions or interventions that may be required or should be avoided in specific situations. This may include circumstances where action needs to be taken if a carer is unable to care for the person. A statement of suggested actions. Usually expressed as: in the event of X do Y.
    treeblank treetree draft  Coded value
    		1 … 1
    prsb03-dataelement-14403link
    The coded value for what should happen SNOMED CT : - <<71388002 |Procedure| OR <<129125009 |Procedure with explicit context|
    treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-14404link
    What should happen (in free text). If 'what should happen' is coded then this is any supplementary or personalised information that relates to the coded value for 'what should happen'. Free text
    treetree folder Who should be contacted
    		0 … *
    prsb03-dataelement-10377link
    Who should be contacted in the event of significant problems or deterioration in health or wellbeing. e.g. name, role and contact details.
    treeblank treetree draft  Name
    		0 … 1
    prsb03-dataelement-14405link
    The name of the professional with responsibility for the care of the person.Free text
    treeblank treetree draft  Role
    		0 … 1
    prsb03-dataelement-14406link
    The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker, key worker, care home manager, care coordinator, LA hospital liaison person, care home contact, hospital clinician, Independent Mental Capacity Advocate (IMCA) etcFHIR values set : - ukcorepractitionerrolecode
    treeblank treetree draft  Contact details
    		0 … 1
    prsb03-dataelement-14407link
    Contact details of the personal contact (e.g. telephone number, address, email address etc.)Free Text
    treetree folder Agreed with person or legitimate representative
    		0 … 1
    prsb03-dataelement-10369link
    Indicates whether the plan was discussed and agreed with the person or legitimate representative.
    treeblank treetree draft  Person or legitimate representative
    		0 … 1
    prsb03-dataelement-14339link
    Indicates whether the plan was discussed and agreed with the person or legitimate representativePerson or legitimate representative 
    treeblank treetree draft  Person full name
    		0 … 1
    prsb03-dataelement-14340link
    The full name of the person in text representation.NHS data dictionary :- Person full name
    treeblank treetree draft  Role
    		0 … 1
    prsb03-dataelement-14341link
    The role the professional has in relation to the person.FHIR value set : - sdsjobrole
    treetree draft  Date this plan was last updated
    		0 … 1
    prsb03-dataelement-10372link
    The date that this contingency plan was last updated.Date and time
    treetree draft  Planned review date/interval
    		0 … 1
    prsb03-dataelement-10373link
    This is the date/interval when this contingency plan will next be reviewed. SNOMED CT tag : - 425268008 | Review of care plan (procedure) |Date and time
    treetree folder Responsibility for review
    		0 … 1
    prsb03-dataelement-10374link
    This is who has responsibility for arranging review of this information.
    treeblank treetree draft  Name
    		0 … 1
    prsb03-dataelement-14342link
    The name of the professional with responsibility for the care of the person.Free text
    treeblank treetree draft  Role
    		0 … 1
    prsb03-dataelement-14343link
    The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker, key worker, care home manager, care coordinator, LA hospital liaison person, care home contact, hospital clinician, Independent Mental Capacity Advocate (IMCA) etcFHIR values set : - ukcorepractitionerrolecode
    treeblank treetree draft  Contact details
    		0 … 1
    prsb03-dataelement-14344link
    Contact details of the professional (e.g. telephone number, email address etc.).Free text
    treetree folder Coping strategies
    		0 … 1
    prsb03-dataelement-13850link
    Details of coping strategies used
    treeblank treetree draft  Coping strategy
    		0 … 1
    prsb03-dataelement-13851link
    The coping strategies are defined as thoughts and behaviours that people use to manage the internal and external demands of situations that are appraised as stressful. This should also include a record of any tools used to carry out the coping strategy.Free text
    treeblank treetree draft  Start date
    		0 … 1
    prsb03-dataelement-13852link
    The date when the coping strategy startedDate and time
    treeblank treetree draft  End date
    		0 … 1
    prsb03-dataelement-13853link
    The date when the coping strategy endedDate and time
    treetree folder Relapse indicators / early warning signs
    		0 … 1
    prsb03-dataelement-13854link
    Details of the relapse indicators for the person. These may also be called 'early warning signs'
    treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-14401link
    The coded value for relapse indicators/early warning signsSNOMED CT : - ^1127601000000107 | Healthcare matters simple reference set (foundation metadata concept) |
    treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-14402link
    Any supplementary or personalised information regarding the relapse indicators/early warning signsFree text
    treetree folder Advance statement
    		0 … 1
    prsb03-dataelement-10777link
    Written requests and preferences made by a person with capacity conveying their wishes, beliefs and values for their future care should they lose capacity.
    treeblank treetree folder Advance statement
    		0 … 1
    prsb03-dataelement-13695link
    Does the person have an advance statement.
    treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-13696link
    The coded value for advance statementSNOMED CT: - 816281000000101 | Has advance statement (Mental Capacity Act 2005) (finding) |
    treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-13697link
    Free text field to be used if no code is availableFree text
    treeblank treetree draft  Location of document
    		1 … 1
    prsb03-dataelement-13760link
    The location of where the advanced statement is held.Free text or URL
    treetree draft  Anticipatory medicines/equipment
    		0 … 1
    prsb03-dataelement-10370link
    Medicines or equipment available that may be required in specific situations and their location. A statement regarding the availability or location of the anticipatory medicines/equipment. SNOMED CT Tag : - 871021000000106 | Prescription of palliative care anticipatory medication (procedure) |Free text
    folder Additional support plans
    		0 … *
    prsb03-dataelement-502link
    Additional support plans
    treetree folder Additional support plan name
    		0 … 1
    prsb03-dataelement-10402link
    The name of the particular additional supporting plan, e.g. dieticians plan, wound management plan, discharge management plan and behaviour support plan.
    treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-14397link
    The coded value for the type of care planSNOMED CT: - 999001471000000108 | Care plan type simple reference set (foundation metadata concept) |
    treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-14398link
    Free text if no coded value is availableFree text
    treetree draft  Additional support plan content
    		0 … 1
    prsb03-dataelement-10403link
    This is the content of any additional care and support plan which the person and/or care professional consider should be shared with others providing care and support. May be structured in different ways, e.g. tables, diagrams, images. This is the content of any additional care and support plan which the individual and/or care professional consider should be shared with others providing care and support. It should be structured as recommended for the care and support plan and if contains additional detail, it may be referenced here.Free text
    treetree draft  Planned review date/interval
    		0 … 1
    prsb03-dataelement-10405link
    This is the date/interval when this information will next be reviewed. SNOMED CT tag : - 425268008 | Review of care plan (procedure) |Date and time
    treetree folder Responsibility for review
    		0 … 1
    prsb03-dataelement-10406link
    This is a record of who has responsibility for arranging review of this information. Should include their name, role and contact details.
    treeblank treetree draft  Name
    		0 … 1
    prsb03-dataelement-14348link
    The name of the professional with responsibility for the care of the person.Free text
    treeblank treetree draft  Role
    		0 … 1
    prsb03-dataelement-14349link
    The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker, key worker, care home manager, care coordinator, LA hospital liaison person, care home contact, hospital clinician, Independent Mental Capacity Advocate (IMCA) etcFHIR values set : - ukcorepractitionerrolecode
    treeblank treetree draft  Contact details
    		0 … 1
    prsb03-dataelement-14350link
    Contact details of the professional (e.g. telephone number, email address etc.).Free text
    treetree draft  Date this plan was last updated
    		0 … 1
    prsb03-dataelement-10407link
    This is a record of the date that this information was last updated.Date and time
    folder Person preferences and treatment objectives
    		0 … 1
    prsb03-dataelement-23081link

    Person’s and carer’s priorities and expectations for treatment, these change over time, NB, person and carer’s objectives may not be consistent, including practicalities, environmental and logistical considerations (transport etc.) These include

    • social preferences, for example being mobile for daughters wedding

    • state of care preferences, for example, reduction of odour or visibility of dressings

    • experience from previous treatments

    • previous equipment experience

    • referred communication method
    treetree draft  What matters to the person
    		0 … *
    prsb03-dataelement-25536link
    A record to establish what matters to the person in the context of the decision to be made, which may include as appropriate:
    • Person goals or hopes: These are 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.
    • Values and preferences: The values and/or preferences that the person holds relating to the decision or otherwise. 
    • Ideas: Opinions, thoughts, or prior knowledge the person has about their diagnosis, prognosis, or options for treatment, investigations, procedures or other areas they feel are relevant.
    • Concerns: Any worries or fears the person has about their diagnosis (or possible diagnosis) or other areas such as treatment, investigations or procedures that may influence their decision-making or they feel are relevant.
    • Expectations: Any expectations or wants of the person relating to treatment, investigations, procedures or other courses of action or other areas they feel are relevant. 
    Free text.
    treetree draft  Previous treatment experience
    		0 … *
    prsb03-dataelement-23083link

    Experience from the person's experience of treatment of similar conditions
    treetree draft  Previous equipment experience
    		0 … *
    prsb03-dataelement-23084link

    A persons experience of using equipment in similar conditions
    treetree draft  Third party preferences
    		0 … *
    prsb03-dataelement-23085link

    Preferences and objectives relating to the treatment of the person, but are stated by a third party, such as next of kin, or carer

    draft rotate Supported Self Care (Supported Self Management)
    prsb03-transaction-438link
    Version / effective date 2022‑10‑31 16:25:03    
    Associations
    Contained concepts
    Concept Card/Conf Id
    folder Documents (including correspondence, audio and images)
    		0 … 1
    prsb03-dataelement-10820link
    Details about documents related to the person.
    treetree folder Documents
    		0 … *
    prsb03-dataelement-11259link
    This is the documents record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
    treeblank treetree draft  Documentation location
    		0 … 1
    prsb03-dataelement-10946link
    The location of the documentFree text or URL
    treeblank treetree draft  Confidentiality
    		0 … 1
    prsb03-dataelement-10942link
    The code specifying the level of confidentiality of the document. FHIR value set : - Confidentiality
    treeblank treetree draft  Class
    		0 … 1
    prsb03-dataelement-10940link
    The document type e.g. report, summary, images, treatment plan, patient preferences, workflowFree text.
    treeblank treetree draft  Document title
    		0 … 1
    prsb03-dataelement-10944link
    The title of the document.Free text
    treeblank treetree draft  Document name
    		0 … 1
    prsb03-dataelement-10945link
    The name of the document. This should align to the PRSB document naming standard. Where the document is a KOS document this field (designated typeCode) is used to carry the DICOM Imaging procedure: This attribute shall be populated by the XDS-I Imaging Document Source from a code in the Procedure Code Sequence (0008,1032) of the performed procedure with which the document is associated. Values may be found in a suitable DICOM browserSNOMED CT: - As per the https://theprsb.org/wp-content/uploads/2018/11/Clinical-document-indexing-standards_NHS-Scotland.pdf
    treeblank treetree draft  Document MIME type
    		0 … 1
    prsb03-dataelement-10949link
    MIME type of the document e.g. application, pdf, audio, jpegFree text
    treeblank treetree folder Service
    		0 … 1
    prsb03-dataelement-11163link
    The high level imaging speciality code e.g. (R-3027B, SRT, “Radiology”)SNOMED CT or free text 999000381000000107 |Correspondence care setting type simple reference set (foundation metadata concept)|
    treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-13749link
    The coded value for serviceSNOMED CT :- 1127531000000102 |Services simple reference set (foundation metadata concept)|
    treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-13750link
    Free text field to be used if no code is availableFree text
    treeblank treetree draft  Comments
    		0 … 1
    prsb03-dataelement-10941link
    Comments associated with the document.Free text
    treeblank treetree folder Additional information required for images.
    		0 … 1
    prsb03-dataelement-12449link
    Additional information required for images.
    treeblank treeblank treetree draft  Image procedure
    		0 … 1
    prsb03-dataelement-12450link
    The procedure used to capture the imageFree text Using DICOM code set https://dicom.innolitics.com/ciods
    treeblank treeblank treetree draft  Image procedure date
    		0 … 1
    prsb03-dataelement-12451link
    The date and time the image procedure was performed.Date and time
    treeblank treeblank treetree folder Images
    		0 … 1
    prsb03-dataelement-11158link
    treeblank treeblank treeblank treetree draft  Image capture date
    		0 … 1
    prsb03-dataelement-11159link
    The date and time when the image was captured.Date and time
    treeblank treeblank treeblank treetree draft  Image ID
    		0 … 1
    prsb03-dataelement-12460link
    A unique image identifier generated by the system.Free text
    treeblank treeblank treeblank treetree draft  Image location
    		0 … 1
    prsb03-dataelement-12461link
    The URL for the imageFree text
    treeblank treeblank treetree draft  Format code
    		0 … 1
    prsb03-dataelement-11161link
    The format code of the document which provides information on how to display the document.Free text
    treeblank treeblank treetree draft  Event code list
    		0 … 1
    prsb03-dataelement-11160link
    The type of image (acquisition modality) and the anatomical site imaged.DICOM code
    treeblank treeblank treetree draft  Comments
    		0 … 1
    prsb03-dataelement-12471link
    Comments associated with the imagingFree text
    folder Structured education
    		0 … *
    prsb03-dataelement-16599link
    Details of the person's participation in structured education programmes. 
    treetree folder Structured education record entry
    		0 … 1
    prsb03-dataelement-16600link
    This is a structured education 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.
    treeblank treetree folder Attendance
    		0 … 1
    prsb03-dataelement-16662link
    Details of the person's attendance on a structured education programme.
    treeblank treeblank treetree folder Attendance
    		0 … 1
    prsb03-dataelement-16664link
    Details of the person's attendance at structured education programme (could be partial or full).
    treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-16665link
    The coded value for attendance.SNOMED CT
    treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-16666link
    Free text field to be used when code is not available.Free text
    treeblank treetree folder Structured education outcome
    		0 … *
    prsb03-dataelement-16697link
    Details of the structured education outcome. 
    treeblank treeblank treetree folder Structured education outcome
    		1 … 1
    prsb03-dataelement-16699link
    The outcome of the structured education programme. 
    treeblank treeblank treeblank treetree draft  Coded value
    		1 … 1
    prsb03-dataelement-16700link
    The coded value for structured education outcome.SNOMED CT
    treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-16701link
    Free text field to be used when code is not available.Free text
    treetree folder Unstructured Education
    		0 … 1
    prsb03-dataelement-26152link

    Not formal education
    treeblank treetree draft  Information and advice given
    		0 … 1
    prsb03-dataelement-26153link
    A description of pertinent aspects, including the information and advice given to the person as part of the team talk. This should include any decision support tools used and where a copy of these can be securely obtained.Free text.
    draft rotate Wound assessment and treatment
    prsb03-transaction-437link
    Version / effective date 2022‑10‑31 16:10:12    
    Description

    The wound assessment and treatment domain is the major development of the standard, the design of this domain supports the use of assessment frameworks such as SINBAD, TIME etc. There are some notable differences between the three wound types, these are identified here by wound type specific data concepts

    Associations
    Contained concepts
    Concept Card/Conf Id
    folder Wound assessment and treatment
    		1 … 1
    prsb03-dataelement-23088link

    Top level concept that contains the wound specific concepts covering

    • baseline information,

    • treatment,

    • assessment

    • observation

    treetree folder Cause of wound
    		0 … 1
    prsb03-dataelement-25879link

    The cause of the wound, coded to SNOMED CT
    treeblank treetree draft  Wound type / classification
    		0 … 1
    prsb03-dataelement-26150link

    1. Wounds should be classified by the dominant cause of wounding and/ or non-healing e.g. diabetic foot ulcer, venous leg ulcer, pressure ulcer etc

    2. Surgical wounds should be classified by the amount of contamination which could lead to delayed wound healing and infection: Clean, Clean-Contaminated, Contaminated, Dirty

    treeblank treetree folder Problem list
    		0 … 1
    prsb03-dataelement-23185link
    A summary of the problems that require investigation or treatment.
    treeblank treeblank treetree folder Problem list record entry
    		1 … *
    prsb03-dataelement-23186link
    This is a problem list record entry.

    There may be 0 to many record entries under problem list.

    Each record entry is made up of a number of elements or data items.
    treeblank treeblank treeblank treetree folder Problem
    		1 … 1
    prsb03-dataelement-23200link
    A condition which needs addressing and so is important for every professional to know about when seeing the person.

    Problems may include diagnoses, symptoms, and social or behavioural issues
    treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-23201link
    The coded value for the problem list.SNOMED CT : - ^1127581000000103 |Health issues simple reference set|
    treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-23202link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treeblank treetree draft  Onset date
    		0 … 1
    prsb03-dataelement-23203link
    A date or estimated date that the problem beganDate and time
    treeblank treeblank treeblank treetree draft  End Date
    		0 … 1
    prsb03-dataelement-23204link
    The date or estimated date the problem was resolved.Date and time.
    treeblank treeblank treeblank treetree folder Severity
    		0 … 1
    prsb03-dataelement-23205link
    The severity of the problem. 
    treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-23206link
    The coded value for severity. SNOMED CT.
    treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-23207link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treeblank treetree folder Body site
    		0 … 1
    prsb03-dataelement-23208link
    The body site relevant to the problem.
    treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-23209link
    The coded value for body site. SNOMED CT.
    treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-23210link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treeblank treetree folder Laterality
    		0 … 1
    prsb03-dataelement-23211link
    The laterality of the problem (left or right).
    treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-23212link
    The coded value for laterality.SNOMED CT.
    treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-23213link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treeblank treetree folder Problem status
    		0 … 1
    prsb03-dataelement-23217link
    The status of the problem. This can be either active or inactive.
    treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-23218link
    The coded value for problem status.SNOMED CT.
    treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-23219link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treeblank treetree folder Problem priority
    		0 … 1
    prsb03-dataelement-23220link
    The problem priority level. This can be either significant or minor. 
    treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-23221link
    The coded value for problem priority. SNOMED CT.
    treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-23222link
    Free text field to be used if no code is availableFree text
    treetree folder Baseline information
    		1 … 1 Mandatory
    prsb03-dataelement-23092link

    Initial description, mapping and number of wounds that exist at the start of the wound care episode

    treeblank treetree folder Wound
    		1 … *
    prsb03-dataelement-26151link

    For each wound
    treeblank treeblank treetree folder Initial (primary) wound assessment
    		1 … 1
    prsb03-dataelement-25537link

    The initial wound assessment, for surgical wounds this is the preoperative assessment
    treeblank treeblank treeblank treetree folder Wound assessment
    		1 … 1
    prsb03-dataelement-25538link

    Periodic assessments, both structured and unstructured, as recommended by best clinical practice (NWCSP)

    treeblank treeblank treeblank treeblank treetree folder Structured assessment
    		0 … 1
    prsb03-dataelement-25539link
    Details of the structured assessment.
    treeblank treeblank treeblank treeblank treeblank treetree folder Structured assessment name
    		0 … 1
    prsb03-dataelement-25551link
    Structured assessment name e.g. New York Heart Failure, Glasgow Coma scale, Activities of Daily Living (ADL) etc.
    treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-25552link
    The coded value for structured assessment name. SNOMED CT: - < 273249006 |Assessment scales (assessment scale)|
    treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-25553link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treeblank treeblank treeblank treetree folder Assessment result
    		0 … 1
    prsb03-dataelement-25554link
    The structured assessment result. This is the overall result for the assessment. 
    treeblank treeblank treeblank treeblank treeblank treeblank treetree folder Assessment score
    		0 … 1
    prsb03-dataelement-25555link
    The overall structured assessment score.
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-25556link
    The coded value for assessment score. SNOMED CT: - < 363787002 |Observable entity (observable entity)|
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-25557link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Value
    		0 … 1
    prsb03-dataelement-25558link
    The numerical value for the assessment result. Enumerated value e.g. numeric, natural numbers. This field is mandatory if the observable entity for assessment item is used.
    treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Units of measure
    		0 … 1
    prsb03-dataelement-25559link
    The units of measure for the assessment result.UCUM code
    treeblank treeblank treeblank treeblank treeblank treeblank treetree folder Ordinal
    		0 … 1
    prsb03-dataelement-25560link
    The ordinal result of the assessment e.g. mild, moderate, severe.
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-25561link
    The coded value for the ordinal result. SNOMED CT.
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-25562link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treeblank treeblank treeblank treetree folder Subscale result
    		0 … *
    prsb03-dataelement-25563link
    The subscale result for the structured assessment. This includes the result for individual questions or subsections.
    treeblank treeblank treeblank treeblank treeblank treeblank treetree folder Subscale score
    		0 … 1
    prsb03-dataelement-25564link
    The subscale score of the structured assessment. Subscales may be individual questions or subsections of the overall assessment. 
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-25565link
    The coded value for subscale item.SNOMED CT: - < 363787002 |Observable entity (observable entity)|
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-25566link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Value
    		0 … 1
    prsb03-dataelement-25567link
    The numerical value for the subscale assessment result. Enumerated value e.g. numeric, natural numbers. This field is mandatory if the observable entity for subscale score is used.
    treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Units of measure
    		0 … 1
    prsb03-dataelement-25568link
    The units of measure for the assessment subscale result.UCUM code
    treeblank treeblank treeblank treeblank treeblank treeblank treetree folder Ordinal
    		0 … 1
    prsb03-dataelement-25569link
    The ordinal result of the subscale assessment e.g. mild, moderate, severe.
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-25570link
    The coded value for the ordinal result. SNOMED CT.
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-25571link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treeblank treeblank treetree folder Wound length, width and depth
    		0 … 1
    prsb03-dataelement-25584link

    The shape and size of the wound
    treeblank treeblank treeblank treeblank treeblank treetree folder Height/length
    		0 … *
    prsb03-dataelement-25585link
    The person's height and length measurement
    treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-25586link
    The coded value for height/lengthSNOMED CT: - 50373000 |Body height measure (observable entity)| OR 248334005 |Length of body (observable entity)|
    treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Value
    		0 … 1
    prsb03-dataelement-25587link
    The value of the observation.Numeric
    treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Units of measure
    		0 … 1
    prsb03-dataelement-25588link
    The units of measure for height/lengthUCUM code
    treeblank treeblank treeblank treeblank treeblank treetree draft  Point of reference
    		0 … 1
    prsb03-dataelement-25592link

    Point of reference for measurements

    treeblank treeblank treeblank treeblank treetree folder Wound and surrounding skin description
    		1 … 1 Mandatory
    prsb03-dataelement-25593link

    Group containing health care professional observations on the wound

    treeblank treeblank treeblank treeblank treeblank treetree draft  Wound margin and edge description
    		1 … 1 Mandatory
    prsb03-dataelement-25594link

    Description of the edge and margins of the wound
    treeblank treeblank treeblank treeblank treeblank treetree draft  Limb shape
    		0 … 1
    prsb03-dataelement-25595link

    A description of the shape of the limb
    treeblank treeblank treeblank treeblank treeblank treetree draft  Foot shape
    		0 … 1
    prsb03-dataelement-25596link

    A description of the shape of the foot
    treeblank treeblank treeblank treeblank treeblank treetree draft  Wound bed tissue type
    		0 … 1
    prsb03-dataelement-25597link

    Description of the bed of the wound
    treeblank treeblank treeblank treeblank treeblank treetree draft  Surrounding skin condition
    		0 … 1
    prsb03-dataelement-25598link

    Description of the surround skin condition
    treeblank treeblank treeblank treeblank treeblank treetree draft  Skin colour
    		0 … 1
    prsb03-dataelement-25599link

    The natural skin colour of the person
    treeblank treeblank treeblank treeblank treetree folder Image of wound
    		0 … 1
    prsb03-dataelement-25600link
    This is the documents record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
    treeblank treeblank treeblank treeblank treeblank treetree draft  Author
    		0 … 1
    prsb03-dataelement-25601link
    The author of the document.Free text
    treeblank treeblank treeblank treeblank treeblank treetree draft  Documentation location
    		0 … 1
    prsb03-dataelement-25611link
    The location of the documentFree text or URL
    treeblank treeblank treeblank treeblank treeblank treetree draft  Confidentiality
    		0 … 1
    prsb03-dataelement-25612link
    The code specifying the level of confidentiality of the document. FHIR value set : - Confidentiality
    treeblank treeblank treeblank treeblank treeblank treetree draft  Class
    		0 … 1
    prsb03-dataelement-25613link
    The document type e.g. report, summary, images, treatment plan, patient preferences, workflowFree text.
    treeblank treeblank treeblank treeblank treeblank treetree draft  Document title
    		0 … 1
    prsb03-dataelement-25614link
    The title of the document.Free text
    treeblank treeblank treeblank treeblank treeblank treetree draft  Document name
    		0 … 1
    prsb03-dataelement-25615link
    The name of the document. This should align to the PRSB document naming standard. Where the document is a KOS document this field (designated typeCode) is used to carry the DICOM Imaging procedure: This attribute shall be populated by the XDS-I Imaging Document Source from a code in the Procedure Code Sequence (0008,1032) of the performed procedure with which the document is associated. Values may be found in a suitable DICOM browserSNOMED CT: - As per the https://theprsb.org/wp-content/uploads/2018/11/Clinical-document-indexing-standards_NHS-Scotland.pdf
    treeblank treeblank treeblank treeblank treeblank treetree draft  Document MIME type
    		0 … 1
    prsb03-dataelement-25616link
    MIME type of the document e.g. application, pdf, audio, jpegFree text
    treeblank treeblank treeblank treeblank treeblank treetree folder Service
    		0 … 1
    prsb03-dataelement-25626link
    The high level imaging speciality code e.g. (R-3027B, SRT, “Radiology”)SNOMED CT or free text 999000381000000107 |Correspondence care setting type simple reference set (foundation metadata concept)|
    treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-25627link
    The coded value for serviceSNOMED CT :- 1127531000000102 |Services simple reference set (foundation metadata concept)|
    treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-25628link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treeblank treeblank treeblank treetree draft  Comments
    		0 … 1
    prsb03-dataelement-25629link
    Comments associated with the document.Free text
    treeblank treeblank treeblank treeblank treeblank treetree folder Additional information required for images.
    		0 … 1
    prsb03-dataelement-25630link
    Additional information required for images.
    treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Image procedure
    		0 … 1
    prsb03-dataelement-25631link
    The procedure used to capture the imageFree text Using DICOM code set https://dicom.innolitics.com/ciods
    treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Image procedure date
    		0 … 1
    prsb03-dataelement-25632link
    The date and time the image procedure was performed.Date and time
    treeblank treeblank treeblank treeblank treeblank treeblank treetree folder Images
    		0 … 1
    prsb03-dataelement-25641link
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Image capture date
    		0 … 1
    prsb03-dataelement-25650link
    The date and time when the image was captured.Date and time
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Image ID
    		0 … 1
    prsb03-dataelement-25651link
    A unique image identifier generated by the system.Free text
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Image location
    		0 … 1
    prsb03-dataelement-25652link
    The URL for the imageFree text
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  mimeType
    		0 … 1
    prsb03-dataelement-25653link
    The type of image.Free text
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Imagine capture date
    		0 … 1
    prsb03-dataelement-25654link
    The date and time when the image was captured.Date and time
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Imagine procedure
    		0 … 1
    prsb03-dataelement-25655link
    The procedure used to capture the image.DICOM code set or free text.
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Unique id
    		0 … 1
    prsb03-dataelement-25656link
    Image generated id.Free text.
    treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Format code
    		0 … 1
    prsb03-dataelement-25657link
    The format code of the document which provides information on how to display the document.Free text
    treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Event code list
    		0 … 1
    prsb03-dataelement-25658link
    The type of image (acquisition modality) and the anatomical site imaged.DICOM code
    treeblank treeblank treeblank treeblank treeblank treeblank treetree folder Person completing record
    		0 … 1
    prsb03-dataelement-25659link
    Details of the person completing the record.
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Name
    		0 … 1
    prsb03-dataelement-25660link
    The name of the person completing the record.Free text.
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Role
    		0 … 1
    prsb03-dataelement-25661link
    The organisational role of the person completing record.FHIR value set :- SDSjobrole
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Grade
    		0 … 1
    prsb03-dataelement-25662link
    The grade of the person completing the record.Free text.
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Specialty
    		0 … 1
    prsb03-dataelement-25663link
    The main specialty of the person completing the record.NHS data dictionary :- Activity treatment function code
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree folder Organisation
    		0 … 1
    prsb03-dataelement-25664link
    The organisation the person completing the record works for. NHS data dictionary : - Organisation data service
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Professional identifier
    		0 … 1
    prsb03-dataelement-25665link
    Professional identifier for the person completing the record e.g. GMC number, HCPC number etc, or the personal identifier used by the local organisation.NHS data dictionary :- Professional registration identifier
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Date completed
    		0 … 1
    prsb03-dataelement-25666link
    The date and time the record was completed.Date and time.
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Contact details
    		0 … 1
    prsb03-dataelement-25667link
    Contact details of the person completing the record.
    NHS data dictionary : - UK telephone number
    treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Comments
    		0 … 1
    prsb03-dataelement-25668link
    Comments associated with the imagingFree text
    treeblank treeblank treeblank treeblank treetree folder Wound complications
    		0 … 1
    prsb03-dataelement-25671link

    Clinical complications which affect the healing of the wound
    treeblank treeblank treeblank treeblank treeblank treetree folder Problem list
    		0 … 1
    prsb03-dataelement-25672link
    A summary of the problems that require investigation or treatment.
    treeblank treeblank treeblank treeblank treeblank treeblank treetree folder Problem list record entry
    		0 … 1
    prsb03-dataelement-25673link
    This is a problem list record entry.

    There may be 0 to many record entries under problem list.

    Each record entry is made up of a number of elements or data items.
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Date
    		0 … 1
    prsb03-dataelement-25674link
    The date the problem was identified.Date and time
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree folder Problem
    		0 … 1
    prsb03-dataelement-25687link
    A condition which needs addressing and so is important for every professional to know about when seeing the person.

    Problems may include diagnoses, symptoms, and social or behavioural issues
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-25688link
    The coded value for the problem list.SNOMED CT : - ^1127581000000103 |Health issues simple reference set|
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-25689link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree folder Severity
    		0 … 1
    prsb03-dataelement-25692link
    The severity of the problem. 
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-25693link
    The coded value for severity. SNOMED CT.
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-25694link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree folder Body site
    		0 … 1
    prsb03-dataelement-25695link
    The body site relevant to the problem.
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-25696link
    The coded value for body site. SNOMED CT.
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-25697link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree folder Laterality
    		0 … 1
    prsb03-dataelement-25698link
    The laterality of the problem (left or right).
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-25699link
    The coded value for laterality.SNOMED CT.
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-25700link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree folder Problem status
    		0 … 1
    prsb03-dataelement-25704link
    The status of the problem. This can be either active or inactive.
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-25705link
    The coded value for problem status.SNOMED CT.
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-25706link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treeblank treeblank treetree folder Vascular Assessment
    		0 … 1
    prsb03-dataelement-25782link

    Assessment to determine the presence and degree of peripheral vascular disease
    treeblank treeblank treeblank treeblank treeblank treetree folder Arterial supply assessment
    		0 … 1
    prsb03-dataelement-25735link

    Assessment of arterial supply to an anatomical location
    treeblank treeblank treeblank treeblank treeblank treeblank treetree folder Structured assessment
    		0 … 1
    prsb03-dataelement-25736link
    Details of the structured assessment.
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree folder Structured assessment name
    		0 … 1
    prsb03-dataelement-25748link
    Structured assessment name e.g. New York Heart Failure, Glasgow Coma scale, Activities of Daily Living (ADL) etc.
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-25749link
    The coded value for structured assessment name. SNOMED CT: - < 273249006 |Assessment scales (assessment scale)|
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-25750link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree folder Assessment result
    		0 … 1
    prsb03-dataelement-25751link
    The structured assessment result. This is the overall result for the assessment. 
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree folder Assessment score
    		0 … 1
    prsb03-dataelement-25752link
    The overall structured assessment score.
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-25753link
    The coded value for assessment score. SNOMED CT: - < 363787002 |Observable entity (observable entity)|
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-25754link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Units of measure
    		0 … 1
    prsb03-dataelement-25756link
    The units of measure for the assessment result.UCUM code
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree folder Ordinal
    		0 … 1
    prsb03-dataelement-25757link
    The ordinal result of the assessment e.g. mild, moderate, severe.
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-25758link
    The coded value for the ordinal result. SNOMED CT.
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-25759link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree folder Subscale result
    		0 … 1
    prsb03-dataelement-25760link
    The subscale result for the structured assessment. This includes the result for individual questions or subsections.
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree folder Subscale score
    		0 … 1
    prsb03-dataelement-25761link
    The subscale score of the structured assessment. Subscales may be individual questions or subsections of the overall assessment. 
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-25762link
    The coded value for subscale item.SNOMED CT: - < 363787002 |Observable entity (observable entity)|
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-25763link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Value
    		0 … 1
    prsb03-dataelement-25764link
    The numerical value for the subscale assessment result. Enumerated value e.g. numeric, natural numbers. This field is mandatory if the observable entity for subscale score is used.
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Units of measure
    		0 … 1
    prsb03-dataelement-25765link
    The units of measure for the assessment subscale result.UCUM code
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree folder Ordinal
    		0 … 1
    prsb03-dataelement-25766link
    The ordinal result of the subscale assessment e.g. mild, moderate, severe.
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-25767link
    The coded value for the ordinal result. SNOMED CT.
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-25768link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treeblank treeblank treeblank treetree folder Structured assessment
    		0 … 1
    prsb03-dataelement-25784link
    Details of the structured assessment.
    treeblank treeblank treeblank treeblank treeblank treeblank treetree folder Structured assessment name
    		0 … 1
    prsb03-dataelement-25796link
    Structured assessment name e.g. New York Heart Failure, Glasgow Coma scale, Activities of Daily Living (ADL) etc.
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-25797link
    The coded value for structured assessment name. SNOMED CT: - < 273249006 |Assessment scales (assessment scale)|
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-25798link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treeblank treeblank treeblank treeblank treetree folder Assessment result
    		0 … 1
    prsb03-dataelement-25799link
    The structured assessment result. This is the overall result for the assessment. 
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree folder Assessment score
    		0 … 1
    prsb03-dataelement-25800link
    The overall structured assessment score.
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-25801link
    The coded value for assessment score. SNOMED CT: - < 363787002 |Observable entity (observable entity)|
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-25802link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Value
    		0 … 1
    prsb03-dataelement-25803link
    The numerical value for the assessment result. Enumerated value e.g. numeric, natural numbers. This field is mandatory if the observable entity for assessment item is used.
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Units of measure
    		0 … 1
    prsb03-dataelement-25804link
    The units of measure for the assessment result.UCUM code
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree folder Ordinal
    		0 … 1
    prsb03-dataelement-25805link
    The ordinal result of the assessment e.g. mild, moderate, severe.
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-25806link
    The coded value for the ordinal result. SNOMED CT.
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-25807link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treeblank treeblank treeblank treeblank treetree folder Subscale result
    		0 … 1
    prsb03-dataelement-25808link
    The subscale result for the structured assessment. This includes the result for individual questions or subsections.
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree folder Subscale score
    		0 … 1
    prsb03-dataelement-25809link
    The subscale score of the structured assessment. Subscales may be individual questions or subsections of the overall assessment. 
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-25810link
    The coded value for subscale item.SNOMED CT: - < 363787002 |Observable entity (observable entity)|
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-25811link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Units of measure
    		0 … 1
    prsb03-dataelement-25813link
    The units of measure for the assessment subscale result.UCUM code
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree folder Ordinal
    		0 … 1
    prsb03-dataelement-25814link
    The ordinal result of the subscale assessment e.g. mild, moderate, severe.
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-25815link
    The coded value for the ordinal result. SNOMED CT.
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-25816link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treeblank treeblank treeblank treetree draft  Ankle–brachial pressure index
    		0 … 1
    prsb03-dataelement-25829link

    The ankle-brachial pressure index (ABPI) or ankle-brachial index (ABI) is the ratio of the blood pressure at the ankle to the blood pressure in the upper arm(brachium). Compared to the arm, lower blood pressure in the leg suggests blocked arteries due to peripheral artery disease (PAD). The ABPI is calculated by dividing the systolic blood pressure at the ankle by the systolic blood pressure in the arm.[1]
    treeblank treeblank treeblank treeblank treeblank treetree draft  Toe pressure index
    		0 … 1
    prsb03-dataelement-25830link

    Commonly used in patients with diabetes and peripheral arterial disease, a toe brachial pressure index (TBPI) is a noninvasive way of determining arterial perfusion in feet and toes. A Doppler device and a sphygmomanometer are used to measure systolic pressure in the arm and the great toe.

    treeblank treeblank treeblank treeblank treetree folder Pressure ulcer category
    		0 … 1
    prsb03-dataelement-25832link

    Formal grading of pressure ulcers
    treeblank treeblank treeblank treeblank treeblank treetree folder Structured assessment
    		0 … 1
    prsb03-dataelement-25833link
    Details of the structured assessment.
    treeblank treeblank treeblank treeblank treeblank treeblank treetree folder Structured assessment name
    		0 … 1
    prsb03-dataelement-25845link
    Structured assessment name e.g. New York Heart Failure, Glasgow Coma scale, Activities of Daily Living (ADL) etc.
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-25846link
    The coded value for structured assessment name. SNOMED CT: - < 273249006 |Assessment scales (assessment scale)|
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-25847link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treeblank treeblank treeblank treeblank treetree folder Assessment result
    		0 … 1
    prsb03-dataelement-25848link
    The structured assessment result. This is the overall result for the assessment. 
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree folder Assessment score
    		0 … 1
    prsb03-dataelement-25849link
    The overall structured assessment score.
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-25850link
    The coded value for assessment score. SNOMED CT: - < 363787002 |Observable entity (observable entity)|
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-25851link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Value
    		0 … 1
    prsb03-dataelement-25852link
    The numerical value for the assessment result. Enumerated value e.g. numeric, natural numbers. This field is mandatory if the observable entity for assessment item is used.
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Units of measure
    		0 … 1
    prsb03-dataelement-25853link
    The units of measure for the assessment result.UCUM code
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree folder Ordinal
    		0 … 1
    prsb03-dataelement-25854link
    The ordinal result of the assessment e.g. mild, moderate, severe.
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-25855link
    The coded value for the ordinal result. SNOMED CT.
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-25856link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treeblank treeblank treeblank treeblank treetree folder Subscale result
    		0 … 1
    prsb03-dataelement-25857link
    The subscale result for the structured assessment. This includes the result for individual questions or subsections.
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree folder Subscale score
    		0 … 1
    prsb03-dataelement-25858link
    The subscale score of the structured assessment. Subscales may be individual questions or subsections of the overall assessment. 
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-25859link
    The coded value for subscale item.SNOMED CT: - < 363787002 |Observable entity (observable entity)|
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-25860link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Value
    		0 … 1
    prsb03-dataelement-25861link
    The numerical value for the subscale assessment result. Enumerated value e.g. numeric, natural numbers. This field is mandatory if the observable entity for subscale score is used.
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Units of measure
    		0 … 1
    prsb03-dataelement-25862link
    The units of measure for the assessment subscale result.UCUM code
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree folder Ordinal
    		0 … 1
    prsb03-dataelement-25863link
    The ordinal result of the subscale assessment e.g. mild, moderate, severe.
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-25864link
    The coded value for the ordinal result. SNOMED CT.
    treeblank treeblank treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-25865link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Person completing record
    		0 … 1
    prsb03-dataelement-25877link
    This is the person recording the individual requirement.

    Should include their name, role, grade, specialty, organisation, professional identifier, date and time completed, contact detailsFree text. Name, Role, Grade, Specialty, Organisation, Professional identifier, Date and time completed, Contact details
    treeblank treeblank treetree folder Anatomical site
    		1 … 1 Mandatory
    prsb03-dataelement-23121link
    The body site of the procedure
    treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-23122link
    The coded value of the anatomical site.SNOMED CT :- <123037004 |Body structure (body structure)|
    treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-23123link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treetree draft  Date wound occurred
    		1 … 1
    prsb03-dataelement-31003link

    To be used to calculate wound duration
    treeblank treetree draft  Body map
    		0 … 1
    prsb03-dataelement-23091link

    Diagram or image showing the location of one or more wounds
    treetree folder Risks
    		0 … *
    prsb03-dataelement-23247link
    Details of any risks related to the person.
    treeblank treetree folder Risks record entry
    		0 … 1
    prsb03-dataelement-23248link
    This is a risks record entry. There may be 0 to many record entry/entries under a section. Each record entry is made up of a number of elements or data items.
    treeblank treeblank treetree draft  Start date of risk
    		1 … 1
    prsb03-dataelement-23249link
    The start date of the risk.Date and time
    treeblank treeblank treetree draft  End date of risk
    		0 … 1
    prsb03-dataelement-23250link
    The date the risk ended.Date and time
    treeblank treeblank treetree folder Risk
    		1 … 1
    prsb03-dataelement-23251link
    The risk to the person or others, this includes any risk the person might cause to themselves or to others. e.g. suicide, self harm. 
    treeblank treeblank treeblank treetree draft  Coded value
    		1 … 1
    prsb03-dataelement-23252link
    The coded value for risk.  SNOMED CT: - <281694009 |Finding of at risk (finding)|  
    treeblank treeblank treeblank treetree draft  Free text
    		1 … 1
    prsb03-dataelement-23253link
    Free text field to be used if no code is available.Free text.
    treeblank treeblank treetree draft  Comment
    		1 … 1
    prsb03-dataelement-23254link
    Additional details about the risk. Free text
    treetree folder Contacts with professionals
    		1 … 1 Mandatory
    prsb03-dataelement-23431link
    The details of the person’s contact with a professional.
    treeblank treetree folder Contacts with professionals record entry
    		1 … 1
    prsb03-dataelement-23432link
    This is a contacts record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
    treeblank treeblank treetree folder Seen by
    		1 … 1
    prsb03-dataelement-23437link
    The professional that saw the person.
    treeblank treeblank treeblank treetree draft  Name
    		1 … 1
    prsb03-dataelement-23438link
    The name of the professional that saw the personFree text
    treeblank treeblank treeblank treetree draft  Role
    		0 … 1
    prsb03-dataelement-23439link
    The role of the person providing the service.FHIR values set : - ukcorepractitionerrolecode
    treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-23440link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treetree draft  Location type
    		1 … 1
    prsb03-dataelement-23444link
    The type of location where the contact took place e.g. person's homeNHS data dictionary - Activity location type code
    treeblank treeblank treetree draft  Reason for service
    		1 … 1
    prsb03-dataelement-23445link
    The reason why the person has been offered the serviceFree text
    treeblank treeblank treetree draft  Contact type
    		1 … 1
    prsb03-dataelement-23449link
    Type of contact e.g. GP consultation, outpatient attendanceFree text
    treeblank treeblank treetree draft  Person accompanying patient
    		0 … 1
    prsb03-dataelement-23463link
    Identify, where clinically relevant, others accompanying the patient, e.g. parent, relative, friend. Includes: Name, Relationship, role (e.g. informal carer).NHS data dictionary : - Person full name
    treetree folder Wound assessment
    		0 … *
    prsb03-dataelement-23474link

    Periodic assessments, both structured and unstructured, as recommended by best clinical practice (NWCSP)

    treeblank treetree folder Structured assessment
    		0 … 1
    prsb03-dataelement-23475link
    Details of the structured assessment.
    treeblank treeblank treetree folder Structured assessment name
    		1 … 1
    prsb03-dataelement-23592link
    Structured assessment name e.g. New York Heart Failure, Glasgow Coma scale, Activities of Daily Living (ADL) etc.
    treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-23593link
    The coded value for structured assessment name. SNOMED CT: - < 273249006 |Assessment scales (assessment scale)|
    treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-23594link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treetree folder Assessment result
    		1 … 1
    prsb03-dataelement-23595link
    The structured assessment result. This is the overall result for the assessment. 
    treeblank treeblank treeblank treetree folder Assessment score
    		0 … 1
    prsb03-dataelement-23596link
    The overall structured assessment score.
    treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-23597link
    The coded value for assessment score. SNOMED CT: - < 363787002 |Observable entity (observable entity)|
    treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-23598link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treeblank treetree draft  Value
    		0 … 1
    prsb03-dataelement-23599link
    The numerical value for the assessment result. Enumerated value e.g. numeric, natural numbers. This field is mandatory if the observable entity for assessment item is used.
    treeblank treeblank treeblank treetree draft  Units of measure
    		0 … 1
    prsb03-dataelement-23600link
    The units of measure for the assessment result.UCUM code
    treeblank treeblank treeblank treetree folder Ordinal
    		0 … 1
    prsb03-dataelement-23601link
    The ordinal result of the assessment e.g. mild, moderate, severe.
    treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-23602link
    The coded value for the ordinal result. SNOMED CT.
    treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-23603link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treetree folder Subscale result
    		0 … *
    prsb03-dataelement-23604link
    The subscale result for the structured assessment. This includes the result for individual questions or subsections.
    treeblank treeblank treeblank treetree folder Subscale score
    		1 … 1
    prsb03-dataelement-23605link
    The subscale score of the structured assessment. Subscales may be individual questions or subsections of the overall assessment. 
    treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-23606link
    The coded value for subscale item.SNOMED CT: - < 363787002 |Observable entity (observable entity)|
    treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-23607link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treeblank treetree draft  Value
    		0 … 1
    prsb03-dataelement-23608link
    The numerical value for the subscale assessment result. Enumerated value e.g. numeric, natural numbers. This field is mandatory if the observable entity for subscale score is used.
    treeblank treeblank treeblank treetree draft  Units of measure
    		0 … 1
    prsb03-dataelement-23609link
    The units of measure for the assessment subscale result.UCUM code
    treeblank treeblank treeblank treetree folder Ordinal
    		0 … 1
    prsb03-dataelement-23610link
    The ordinal result of the subscale assessment e.g. mild, moderate, severe.
    treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-23611link
    The coded value for the ordinal result. SNOMED CT.
    treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-23612link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Wound length, width and depth
    		1 … 1
    prsb03-dataelement-23096link

    The shape and size of the wound
    treeblank treeblank treetree folder Height/length
    		0 … *
    prsb03-dataelement-25468link
    The person's height and length measurement
    treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-25469link
    The coded value for height/lengthSNOMED CT: - 50373000 |Body height measure (observable entity)| OR 248334005 |Length of body (observable entity)|
    treeblank treeblank treeblank treetree draft  Value
    		0 … 1
    prsb03-dataelement-25470link
    The value of the observation.Numeric
    treeblank treeblank treeblank treetree draft  Units of measure
    		1 … 1
    prsb03-dataelement-25471link
    The units of measure for height/lengthUCUM code
    treeblank treeblank treetree cancelled  Height/Length
    		0 … 1
    prsb03-dataelement-23097link
    Numeric value for the body length.
    treeblank treeblank treetree cancelled  Width
    		0 … 1
    prsb03-dataelement-23098link

    The width of the wound
    treeblank treeblank treetree cancelled  Depth
    		0 … 1
    prsb03-dataelement-23099link

    The depth of the wound
    treeblank treeblank treetree draft  Point of reference
    		1 … 1
    prsb03-dataelement-23100link

    Point of reference for measurements

    treeblank treetree folder Wound and surrounding skin description
    		1 … 1 Mandatory
    prsb03-dataelement-25472link

    Group containing health care professional observations on the wound

    treeblank treeblank treetree draft  Wound margin and edge description
    		1 … 1 Mandatory
    prsb03-dataelement-23102link

    Description of the edge and margins of the wound
    treeblank treeblank treetree draft  Limb shape
    		1 … 1
    prsb03-dataelement-23630link

    A description of the shape of the limb
    treeblank treeblank treetree draft  Foot shape
    		0 … 1
    prsb03-dataelement-23631link

    A description of the shape of the foot
    treeblank treeblank treetree draft  Wound bed tissue type
    		1 … 1
    prsb03-dataelement-23101link

    Description of the bed of the wound
    treeblank treeblank treetree draft  Surrounding skin condition
    		1 … 1
    prsb03-dataelement-23103link

    Description of the surround skin condition
    treeblank treeblank treetree draft  Skin colour
    		0 … 1
    prsb03-dataelement-23095link

    The natural skin colour of the person
    treeblank treetree folder Image of wound
    		0 … 1
    prsb03-dataelement-23632link
    This is the documents record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
    treeblank treeblank treetree draft  Documentation location
    		1 … 1
    prsb03-dataelement-23643link
    The location of the documentFree text or URL
    treeblank treeblank treetree draft  Confidentiality
    		1 … 1
    prsb03-dataelement-23644link
    The code specifying the level of confidentiality of the document. FHIR value set : - Confidentiality
    treeblank treeblank treetree draft  Class
    		1 … 1
    prsb03-dataelement-23645link
    The document type e.g. report, summary, images, treatment plan, patient preferences, workflowFree text.
    treeblank treeblank treetree draft  Document title
    		1 … 1
    prsb03-dataelement-23646link
    The title of the document.Free text
    treeblank treeblank treetree draft  Document name
    		1 … 1
    prsb03-dataelement-23647link
    The name of the document. This should align to the PRSB document naming standard. Where the document is a KOS document this field (designated typeCode) is used to carry the DICOM Imaging procedure: This attribute shall be populated by the XDS-I Imaging Document Source from a code in the Procedure Code Sequence (0008,1032) of the performed procedure with which the document is associated. Values may be found in a suitable DICOM browserSNOMED CT: - As per the https://theprsb.org/wp-content/uploads/2018/11/Clinical-document-indexing-standards_NHS-Scotland.pdf
    treeblank treeblank treetree draft  Document MIME type
    		1 … 1
    prsb03-dataelement-23648link
    MIME type of the document e.g. application, pdf, audio, jpegFree text
    treeblank treeblank treetree draft  Comments
    		0 … 1
    prsb03-dataelement-23661link
    Comments associated with the document.Free text
    treeblank treetree folder Wound complications
    		0 … *
    prsb03-dataelement-25473link

    Clinical complications which affect the healing of the wound
    treeblank treeblank treetree folder Problem list
    		1 … 1
    prsb03-dataelement-25474link
    A summary of the problems that require investigation or treatment.
    treeblank treeblank treeblank treetree folder Problem list record entry
    		1 … 1
    prsb03-dataelement-25475link
    This is a problem list record entry.

    There may be 0 to many record entries under problem list.

    Each record entry is made up of a number of elements or data items.
    treeblank treeblank treeblank treeblank treetree folder Problem
    		1 … 1
    prsb03-dataelement-25489link
    A condition which needs addressing and so is important for every professional to know about when seeing the person.

    Problems may include diagnoses, symptoms, and social or behavioural issues
    treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-25490link
    The coded value for the problem list.SNOMED CT : - ^1127581000000103 |Health issues simple reference set|
    treeblank treeblank treeblank treeblank treeblank treetree draft  Free text
    		1 … 1
    prsb03-dataelement-25491link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treeblank treeblank treetree draft  Onset date
    		0 … 1
    prsb03-dataelement-25492link
    A date or estimated date that the problem beganDate and time
    treeblank treeblank treeblank treeblank treetree draft  End Date
    		0 … 1
    prsb03-dataelement-25493link
    The date or estimated date the problem was resolved.Date and time.
    treeblank treeblank treeblank treeblank treetree folder Severity
    		0 … 1
    prsb03-dataelement-25494link
    The severity of the problem. 
    treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
    		1 … 1
    prsb03-dataelement-25495link
    The coded value for severity. SNOMED CT.
    treeblank treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-25496link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treeblank treeblank treetree folder Body site
    		0 … 1
    prsb03-dataelement-25497link
    The body site relevant to the problem.
    treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-25498link
    The coded value for body site. SNOMED CT.
    treeblank treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-25499link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treeblank treeblank treetree folder Laterality
    		0 … 1
    prsb03-dataelement-25500link
    The laterality of the problem (left or right).
    treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-25501link
    The coded value for laterality.SNOMED CT.
    treeblank treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-25502link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treeblank treeblank treetree folder Problem status
    		0 … 1
    prsb03-dataelement-25506link
    The status of the problem. This can be either active or inactive.
    treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-25507link
    The coded value for problem status.SNOMED CT.
    treeblank treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-25508link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treeblank treeblank treetree folder Problem priority
    		0 … 1
    prsb03-dataelement-25509link
    The problem priority level. This can be either significant or minor. 
    treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-25510link
    The coded value for problem priority. SNOMED CT.
    treeblank treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-25511link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Vascular Assessment
    		0 … 1
    prsb03-dataelement-24524link

    Assessment to determine the presence and degree of peripheral vascular disease
    treeblank treeblank treetree folder Arterial supply assessment
    		0 … 1
    prsb03-dataelement-24373link

    Assessment of arterial supply to an anatomical location
    treeblank treeblank treeblank treetree folder Structured assessment
    		0 … 1
    prsb03-dataelement-24374link
    Details of the structured assessment.
    treeblank treeblank treeblank treeblank treetree folder Structured assessment name
    		0 … 1
    prsb03-dataelement-24491link
    Structured assessment name e.g. New York Heart Failure, Glasgow Coma scale, Activities of Daily Living (ADL) etc.
    treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-24492link
    The coded value for structured assessment name. SNOMED CT: - < 273249006 |Assessment scales (assessment scale)|
    treeblank treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-24493link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treeblank treeblank treetree folder Assessment result
    		1 … 1
    prsb03-dataelement-24494link
    The structured assessment result. This is the overall result for the assessment. 
    treeblank treeblank treeblank treeblank treeblank treetree folder Assessment score
    		1 … 1
    prsb03-dataelement-24495link
    The overall structured assessment score.
    treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-24496link
    The coded value for assessment score. SNOMED CT: - < 363787002 |Observable entity (observable entity)|
    treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-24497link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treeblank treeblank treeblank treetree draft  Value
    		0 … 1
    prsb03-dataelement-24498link
    The numerical value for the assessment result. Enumerated value e.g. numeric, natural numbers. This field is mandatory if the observable entity for assessment item is used.
    treeblank treeblank treeblank treeblank treeblank treetree draft  Units of measure
    		0 … 1
    prsb03-dataelement-24499link
    The units of measure for the assessment result.UCUM code
    treeblank treeblank treeblank treeblank treeblank treetree folder Ordinal
    		0 … 1
    prsb03-dataelement-24500link
    The ordinal result of the assessment e.g. mild, moderate, severe.
    treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-24501link
    The coded value for the ordinal result. SNOMED CT.
    treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-24502link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treeblank treeblank treetree folder Subscale result
    		0 … 1
    prsb03-dataelement-24503link
    The subscale result for the structured assessment. This includes the result for individual questions or subsections.
    treeblank treeblank treeblank treeblank treeblank treetree folder Subscale score
    		0 … 1
    prsb03-dataelement-24504link
    The subscale score of the structured assessment. Subscales may be individual questions or subsections of the overall assessment. 
    treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-24505link
    The coded value for subscale item.SNOMED CT: - < 363787002 |Observable entity (observable entity)|
    treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-24506link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treeblank treeblank treeblank treetree draft  Value
    		0 … 1
    prsb03-dataelement-24507link
    The numerical value for the subscale assessment result. Enumerated value e.g. numeric, natural numbers. This field is mandatory if the observable entity for subscale score is used.
    treeblank treeblank treeblank treeblank treeblank treetree draft  Units of measure
    		0 … 1
    prsb03-dataelement-24508link
    The units of measure for the assessment subscale result.UCUM code
    treeblank treeblank treeblank treeblank treeblank treetree folder Ordinal
    		0 … 1
    prsb03-dataelement-24509link
    The ordinal result of the subscale assessment e.g. mild, moderate, severe.
    treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-24510link
    The coded value for the ordinal result. SNOMED CT.
    treeblank treeblank treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-24511link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treetree folder Structured assessment
    		0 … 1
    prsb03-dataelement-24525link
    Details of the structured assessment.
    treeblank treeblank treeblank treetree folder Structured assessment name
    		0 … 1
    prsb03-dataelement-24537link
    Structured assessment name e.g. New York Heart Failure, Glasgow Coma scale, Activities of Daily Living (ADL) etc.
    treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-24538link
    The coded value for structured assessment name. SNOMED CT: - < 273249006 |Assessment scales (assessment scale)|
    treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-24539link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treeblank treetree folder Assessment result
    		0 … 1
    prsb03-dataelement-24540link
    The structured assessment result. This is the overall result for the assessment. 
    treeblank treeblank treeblank treeblank treetree folder Assessment score
    		0 … 1
    prsb03-dataelement-24541link
    The overall structured assessment score.
    treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-24542link
    The coded value for assessment score. SNOMED CT: - < 363787002 |Observable entity (observable entity)|
    treeblank treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-24543link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treeblank treeblank treetree draft  Value
    		0 … 1
    prsb03-dataelement-24544link
    The numerical value for the assessment result. Enumerated value e.g. numeric, natural numbers. This field is mandatory if the observable entity for assessment item is used.
    treeblank treeblank treeblank treeblank treetree draft  Units of measure
    		0 … 1
    prsb03-dataelement-24545link
    The units of measure for the assessment result.UCUM code
    treeblank treeblank treeblank treeblank treetree folder Ordinal
    		0 … 1
    prsb03-dataelement-24546link
    The ordinal result of the assessment e.g. mild, moderate, severe.
    treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-24547link
    The coded value for the ordinal result. SNOMED CT.
    treeblank treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-24548link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treeblank treetree folder Subscale result
    		0 … *
    prsb03-dataelement-24549link
    The subscale result for the structured assessment. This includes the result for individual questions or subsections.
    treeblank treeblank treeblank treeblank treetree folder Subscale score
    		0 … 1
    prsb03-dataelement-24550link
    The subscale score of the structured assessment. Subscales may be individual questions or subsections of the overall assessment. 
    treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-24551link
    The coded value for subscale item.SNOMED CT: - < 363787002 |Observable entity (observable entity)|
    treeblank treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-24552link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treeblank treeblank treetree draft  Value
    		0 … 1
    prsb03-dataelement-24553link
    The numerical value for the subscale assessment result. Enumerated value e.g. numeric, natural numbers. This field is mandatory if the observable entity for subscale score is used.
    treeblank treeblank treeblank treeblank treetree draft  Units of measure
    		0 … 1
    prsb03-dataelement-24554link
    The units of measure for the assessment subscale result.UCUM code
    treeblank treeblank treeblank treeblank treetree folder Ordinal
    		0 … 1
    prsb03-dataelement-24555link
    The ordinal result of the subscale assessment e.g. mild, moderate, severe.
    treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-24556link
    The coded value for the ordinal result. SNOMED CT.
    treeblank treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-24557link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treetree draft  Ankle–brachial pressure index
    		0 … 1
    prsb03-dataelement-23627link

    The ankle-brachial pressure index (ABPI) or ankle-brachial index (ABI) is the ratio of the blood pressure at the ankle to the blood pressure in the upper arm(brachium). Compared to the arm, lower blood pressure in the leg suggests blocked arteries due to peripheral artery disease (PAD). The ABPI is calculated by dividing the systolic blood pressure at the ankle by the systolic blood pressure in the arm.[1]
    treeblank treeblank treetree draft  Toe pressure index
    		0 … 1
    prsb03-dataelement-23625link

    Commonly used in patients with diabetes and peripheral arterial disease, a toe brachial pressure index (TBPI) is a noninvasive way of determining arterial perfusion in feet and toes. A Doppler device and a sphygmomanometer are used to measure systolic pressure in the arm and the great toe.

    treeblank treetree folder Pressure ulcer category
    		1 … 1
    prsb03-dataelement-24570link

    Formal grading of pressure ulcers
    treeblank treeblank treetree folder Structured assessment
    		0 … 1
    prsb03-dataelement-24571link
    Details of the structured assessment.
    treeblank treeblank treeblank treetree folder Structured assessment name
    		1 … 1
    prsb03-dataelement-24583link
    Structured assessment name e.g. New York Heart Failure, Glasgow Coma scale, Activities of Daily Living (ADL) etc.
    treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-24584link
    The coded value for structured assessment name. SNOMED CT: - < 273249006 |Assessment scales (assessment scale)|
    treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-24585link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treeblank treetree folder Assessment result
    		0 … 1
    prsb03-dataelement-24586link
    The structured assessment result. This is the overall result for the assessment. 
    treeblank treeblank treeblank treeblank treetree folder Assessment score
    		1 … 1
    prsb03-dataelement-24587link
    The overall structured assessment score.
    treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-24588link
    The coded value for assessment score. SNOMED CT: - < 363787002 |Observable entity (observable entity)|
    treeblank treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-24589link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treeblank treeblank treetree draft  Value
    		0 … 1
    prsb03-dataelement-24590link
    The numerical value for the assessment result. Enumerated value e.g. numeric, natural numbers. This field is mandatory if the observable entity for assessment item is used.
    treeblank treeblank treeblank treeblank treetree draft  Units of measure
    		0 … 1
    prsb03-dataelement-24591link
    The units of measure for the assessment result.UCUM code
    treeblank treeblank treeblank treeblank treetree folder Ordinal
    		0 … 1
    prsb03-dataelement-24592link
    The ordinal result of the assessment e.g. mild, moderate, severe.
    treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-24593link
    The coded value for the ordinal result. SNOMED CT.
    treeblank treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-24594link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treeblank treetree folder Subscale result
    		0 … *
    prsb03-dataelement-24595link
    The subscale result for the structured assessment. This includes the result for individual questions or subsections.
    treeblank treeblank treeblank treeblank treetree folder Subscale score
    		0 … 1
    prsb03-dataelement-24596link
    The subscale score of the structured assessment. Subscales may be individual questions or subsections of the overall assessment. 
    treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-24597link
    The coded value for subscale item.SNOMED CT: - < 363787002 |Observable entity (observable entity)|
    treeblank treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-24598link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treeblank treeblank treetree draft  Value
    		0 … 1
    prsb03-dataelement-24599link
    The numerical value for the subscale assessment result. Enumerated value e.g. numeric, natural numbers. This field is mandatory if the observable entity for subscale score is used.
    treeblank treeblank treeblank treeblank treetree draft  Units of measure
    		0 … 1
    prsb03-dataelement-24600link
    The units of measure for the assessment subscale result.UCUM code
    treeblank treeblank treeblank treeblank treetree folder Ordinal
    		0 … 1
    prsb03-dataelement-24601link
    The ordinal result of the subscale assessment e.g. mild, moderate, severe.
    treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-24602link
    The coded value for the ordinal result. SNOMED CT.
    treeblank treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-24603link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treeblank treetree draft  Subscale score
    		0 … 1
    prsb03-dataelement-24604link
    The subscale score of the structured assessment.Free text.
    treeblank treeblank treeblank treetree draft  Subscale value
    		0 … 1
    prsb03-dataelement-24605link
    The subscale value of the structured assessment.Numeric
    treetree folder Wound observations
    		1 … *
    prsb03-dataelement-23703link

    Observations relating to the wound care episode
    treeblank treetree folder Clinical observations
    		1 … *
    prsb03-dataelement-23105link

    Observations that health care professionals make

    treeblank treeblank treetree folder Pain score
    		0 … 1
    prsb03-dataelement-23704link
    The pain score for the person
    treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-23705link
    The coded value for pain scoreSNOMED CT : - 225908003 | Pain score (observable entity) |
    treeblank treeblank treeblank treetree draft  Value
    		0 … 1
    prsb03-dataelement-23706link
    The value for the pain scoreNumeric
    treeblank treeblank treeblank treetree draft  Units of measure
    		0 … 1
    prsb03-dataelement-23707link
    The units of measure for pain scoreUCUM
    treeblank treeblank treetree draft  Signs and symptoms of infection
    		1 … 1 Mandatory
    prsb03-dataelement-23106link

    is infection present, SSI
    treeblank treeblank treetree folder Exudate
    		0 … 1
    prsb03-dataelement-23108link

    Record of discharge from the wound
    treeblank treeblank treeblank treetree draft  Exudate amount
    		0 … 1
    prsb03-dataelement-23109link

    The observed quantity of discharge
    treeblank treeblank treeblank treetree draft  Exudate consistency
    		0 … 1
    prsb03-dataelement-23110link

    The consistency of the discharge

    treeblank treeblank treeblank treetree draft  Exudate type
    		0 … 1
    prsb03-dataelement-23111link

    The type of discharge that is coming from the wound
    treeblank treeblank treeblank treetree draft  Exudate colour
    		0 … 1
    prsb03-dataelement-23112link

    The colour or the discharge
    treeblank treeblank treetree folder Wound care product performance
    		0 … 1
    prsb03-dataelement-24265link

    Care professionals assessment on how the wound care product (for example dressing) is performing

    treeblank treeblank treeblank treetree draft  Dressing performance
    		0 … 1
    prsb03-dataelement-23709link

    is the dressing in use effective
    treeblank treeblank treetree draft  Odour intensity
    		0 … 1
    prsb03-dataelement-23107link

    Presence and degree of odour
    treeblank treeblank treetree folder Examination type
    		0 … *
    prsb03-dataelement-25465link
    The type of examination performed.
    treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-25466link
    The coded value for examination type. SNOMED CT.
    treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-25467link
    Free text field to be used if no code is available
    treeblank treeblank treetree folder Examination findings
    		0 … *
    prsb03-dataelement-24645link
    The record of findings from the examinations performed.
    treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-25463link
    The coded value for examination findings.SNOMED CT : - ^1127601000000107 |Healthcare matters simple reference set (foundation metadata concept)|
    treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-25464link
    Free text field to be used if no coded text available
    treeblank treeblank treetree draft  Pulse sounds
    		0 … 1
    prsb03-dataelement-23116link

    The sound of a pulse
    treeblank treeblank treetree folder Joint mobility
    		0 … *
    prsb03-dataelement-23712link

    Is the joint mobile
    treeblank treeblank treeblank treetree folder Anatomical site
    		0 … 1
    prsb03-dataelement-23713link
    The body site of the procedure
    treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-23714link
    The coded value of the anatomical site.SNOMED CT :- <123037004 |Body structure (body structure)|
    treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-23715link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treeblank treetree draft  Mobility assessment
    		0 … 1
    prsb03-dataelement-23716link

    Degree of mobility in the joint
    treeblank treeblank treetree draft  Posture and positioning
    		0 … 1
    prsb03-dataelement-23711link

    Position that the limb is in
    treeblank treeblank treetree draft  Lower limb oedema
    		0 … 1
    prsb03-dataelement-23710link

    Swelling in the ankles, feet and legs is often caused by a build-up of fluid in these areas, called oedema. Oedema is usually caused by: standing or sitting in the same position for too long. eating too much salty food.

    treeblank treeblank treetree draft  Sensitivity and sensation
    		0 … 1
    prsb03-dataelement-23117link

    The sensitivity and reported sensation

    treeblank treeblank treetree folder Temperature
    		0 … 1
    prsb03-dataelement-24618link
    The measurement of the person's temperature in Celsius (OC)
    treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-24619link
    The coded value for tempretureSNOMED CT : -<<386725007 |Body temperature (observable entity)|
    treeblank treeblank treeblank treetree draft  Value
    		0 … 1
    prsb03-dataelement-24620link
    The value of the person tempretureNumeric
    treeblank treeblank treeblank treetree draft  Units of measure
    		0 … 1
    prsb03-dataelement-24621link
    The units of measure for the persons tempretureUCUM code
    treeblank treeblank treetree folder Observations record entry
    		0 … *
    prsb03-dataelement-24622link
    This is an observations record entry. There may be 0 to many record entry/entries under a section. Each record entry is made up of a number of elements or data items.
    treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-24637link
    The coded value for observationsSNOMED CT: - <363787002 | Observable entity (observable entity) |
    treeblank treeblank treeblank treetree draft  Value
    		0 … 1
    prsb03-dataelement-24638link
    The measured value of the observationsEnumerated value e.g. numeric, natural numbers, mild, moderate
    treeblank treeblank treetree draft  Observed nutritional status
    		0 … 1
    prsb03-dataelement-23119link

    The nutritional status of the person
    treeblank treetree folder Person observations
    		0 … 1
    prsb03-dataelement-23115link

    Observations noted and reported by the person
    treeblank treeblank treetree draft  Observations
    		1 … 1
    prsb03-dataelement-23124link
    The record of essential physiological observations e.g pulse, blood pressure, oxygen saturation/capnography, temperature, pain score, respiration rate, level of consciousness or new confusion. Use of National Early Warning Score (NEWS2) where appropriate.FHIR NEWS2 specification produced by NHS Digital and the associated observations. See implmentation guidance for restriction of the use of NEWS2 by age.
    treetree folder Wound and skin care treatment
    		1 … 1
    prsb03-dataelement-23120link

    Treatments that are peculiar to wound care
    treeblank treetree folder Wound care products
    		0 … *
    prsb03-dataelement-23717link

    Dressing applied to wound
    treeblank treeblank treetree folder Medication item entry
    		0 … 1
    prsb03-dataelement-24008link
    All medications and devices that can be prescribed to be entered via this Medication item entry. Handles details of continuation / addition / amendment of admission medications.
    treeblank treeblank treeblank treetree folder Medication item cluster
    		1 … 1
    prsb03-dataelement-24009link
    Medication item cluster
    treeblank treeblank treeblank treeblank treetree draft  Medication prescribed by
    		1 … 1
    prsb03-dataelement-24023link
    The type of organisation responsible for authorising and issuing the medication e.g. GP
    FHIR value set : - Medication prescribing agency
    treeblank treeblank treeblank treeblank treetree folder Medication name
    		1 … 1
    prsb03-dataelement-24024link
    May be generic name or brand name.
    treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
    		1 … 1
    prsb03-dataelement-24025link
    The coded value for medication namedm+d:- any code from the VTM, VMP, AMP, VMPP and AMPP concept classes
    treeblank treeblank treeblank treeblank treeblank treetree draft  Free text
    		1 … 1
    prsb03-dataelement-24026link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treeblank treeblank treetree folder Medication trade family
    		1 … 1
    prsb03-dataelement-24027link
    The trade family or brand of the medication prescribed.
    treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
    		1 … 1
    prsb03-dataelement-24028link
    The coded value for medication trade family or brand.SNOMED CT: - 999000631000001100 |National Health Service dictionary of medicines and devices trade family simple reference set (foundation metadata concept)|
    treeblank treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-24029link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treeblank treeblank treetree folder Form
    		1 … 1
    prsb03-dataelement-24030link
    The form of the medication e.g. capsule, drops, tablet, lotion etc.
    treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
    		1 … 1
    prsb03-dataelement-24031link
    The coded value for form.SNOMED CT: - ^999000781000001107 | National Health Service dictionary of medicines and devices dose form simple reference set (foundation metadata concept) |
    treeblank treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-24032link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treeblank treeblank treetree folder Quantity supplied
    		1 … 1
    prsb03-dataelement-24033link
    The quantity of the medication (e.g. tablets, inhalers, etc.) provided to the person. This may be dispensed by the pharmacy or on the ward. Record in a structured format i.e. value and a unitFree text
    treeblank treeblank treeblank treeblank treeblank treetree draft  Value
    		1 … 1
    prsb03-dataelement-24034link
    The value of the quantity suppliedEnumerated value
    treeblank treeblank treeblank treeblank treeblank treetree draft  Units of measure
    		1 … 1
    prsb03-dataelement-24035link
    Units of measure of quantity supplied
    UCUM code
    treeblank treeblank treeblank treeblank treetree draft  Date supplied
    		1 … 1
    prsb03-dataelement-24036link
    The date/time the medication was supplied.Date and time
    treeblank treeblank treeblank treeblank treetree folder Site
    		1 … 1
    prsb03-dataelement-24040link
    The anatomical site at which the medication is to be administered.
    treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-24041link
    The coded value for siteSNOMED CT: - <442083009 | Anatomical or acquired body structure (body structure) |
    treeblank treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-24042link
    Free text field to be used when code is not availableFree text
    treeblank treeblank treeblank treeblank treetree folder Method
    		1 … 1
    prsb03-dataelement-24043link
    The technique or method by which the medication is to be administered.
    treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-24044link
    The coded value for methodSNOMED CT : - ^999000041000001103 | ePrescribing method simple reference set (foundation metadata concept) |
    treeblank treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-24045link
    Free text field to be used if no coded text available
    treeblank treeblank treeblank treeblank treetree draft  Supply type
    		0 … 1
    prsb03-dataelement-24046link
    A description of the type of supply (e.g. emergency supply, over the counter medication, patient group direction etc)
    treeblank treeblank treeblank treeblank treetree folder Batch number
    		0 … 1
    prsb03-dataelement-24048link
    The batch number of the product.
    treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-24049link
    The coded value for the batch numberFMD code : - Derived from Falsified medicines directive
    treeblank treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-24050link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treeblank treeblank treetree draft  Additional instructions
    		0 … 1
    prsb03-dataelement-24069link
    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.FHIR value set : - Additional instruction
    treeblank treeblank treeblank treeblank treetree draft  Request for advice
    		0 … 1
    prsb03-dataelement-24070link
    Request for advice and recommendation about medicationFree text
    treeblank treeblank treeblank treeblank treetree draft  Matters identified during discussion
    		0 … *
    prsb03-dataelement-24071link
    Matters identified during the service about the patient's experience of using the medication. Coded text using the following descriptors: a. patient reports using the medicine as prescribed b. patient reports not using the medicine as prescribed c. patient has not started using the medicine d. prescriber has stopped new medicine e. patient is not using the medicine in line with the directions of the prescriber f. patient reports missing a dose in the past 7 days g. patient reports need for more information about the medicine h. patient reports side effects i. patient reports negative feelings about the medicine j. patient reports uncertainty on whether the medicine is working k. patient reports concern about remembering to take the medicine l. patient reports difficulty using the medicine due to its pharmaceutical form/formulation i. other - free text option
    treeblank treeblank treetree folder Medical devices entry
    		0 … 1
    prsb03-dataelement-23718link
    Medical devices
    treeblank treeblank treeblank treetree folder Medical device
    		1 … 1
    prsb03-dataelement-23719link
    Details of a medical device used by the person.
    treeblank treeblank treeblank treeblank treetree folder Device type
    		0 … 1
    prsb03-dataelement-23720link
    The device type. 
    treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-23721link
    The coded value for device type.SNOMED CT.
    treeblank treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-23722link
    Free text field to be used if no code is available.Free text.
    treeblank treeblank treeblank treeblank treetree folder Device manufacturer
    		0 … 1
    prsb03-dataelement-23723link
    Name of the device manufacturer.
    treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-23724link
    The coded value for device manufacturer.SNOMED CT.
    treeblank treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-23725link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treeblank treeblank treetree folder Model
    		0 … 1
    prsb03-dataelement-23726link
    The model of the device.
    treeblank treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-23727link
    The coded value for model.SNOMED CT.
    treeblank treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-23728link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treeblank treetree draft  Comments
    		0 … 1
    prsb03-dataelement-23737link
    Any information regarding the medical device.Free text
    treeblank treetree folder Medication item entry
    		0 … 1
    prsb03-dataelement-23738link
    All medications and devices that can be prescribed to be entered via this Medication item entry. Handles details of continuation / addition / amendment of admission medications.
    treeblank treeblank treetree folder Medication item cluster
    		1 … 1
    prsb03-dataelement-23739link
    Medication item cluster
    treeblank treeblank treeblank treetree draft  Medication prescribed by
    		1 … 1
    prsb03-dataelement-23753link
    The type of organisation responsible for authorising and issuing the medication e.g. GP
    FHIR value set : - Medication prescribing agency
    treeblank treeblank treeblank treetree folder Medication name
    		1 … 1
    prsb03-dataelement-23754link
    May be generic name or brand name.
    treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-23755link
    The coded value for medication namedm+d:- any code from the VTM, VMP, AMP, VMPP and AMPP concept classes
    treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-23756link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treeblank treetree folder Medication trade family
    		1 … 1
    prsb03-dataelement-23757link
    The trade family or brand of the medication prescribed.
    treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-23758link
    The coded value for medication trade family or brand.SNOMED CT: - 999000631000001100 |National Health Service dictionary of medicines and devices trade family simple reference set (foundation metadata concept)|
    treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-23759link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treeblank treetree folder Form
    		1 … 1
    prsb03-dataelement-23760link
    The form of the medication e.g. capsule, drops, tablet, lotion etc.
    treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-23761link
    The coded value for form.SNOMED CT: - ^999000781000001107 | National Health Service dictionary of medicines and devices dose form simple reference set (foundation metadata concept) |
    treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-23762link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treeblank treetree folder Quantity supplied
    		1 … 1
    prsb03-dataelement-23763link
    The quantity of the medication (e.g. tablets, inhalers, etc.) provided to the person. This may be dispensed by the pharmacy or on the ward. Record in a structured format i.e. value and a unitFree text
    treeblank treeblank treeblank treeblank treetree draft  Value
    		0 … 1
    prsb03-dataelement-23764link
    The value of the quantity suppliedEnumerated value
    treeblank treeblank treeblank treeblank treetree draft  Units of measure
    		0 … 1
    prsb03-dataelement-23765link
    Units of measure of quantity supplied
    UCUM code
    treeblank treeblank treeblank treetree draft  Date supplied
    		1 … 1
    prsb03-dataelement-23766link
    The date/time the medication was supplied.Date and time
    treeblank treeblank treeblank treetree folder Route
    		1 … 1
    prsb03-dataelement-23767link
    The route by which the medication is administered e.g. oral, IM, IV
    treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-23768link
    The coded value for routeSNOMED CT: - ^999000051000001100 |ePrescribing route of administration simple reference set (foundation metadata concept)|
    treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-23769link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treeblank treetree folder Site
    		1 … 1
    prsb03-dataelement-23770link
    The anatomical site at which the medication is to be administered.
    treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-23771link
    The coded value for siteSNOMED CT: - <442083009 | Anatomical or acquired body structure (body structure) |
    treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-23772link
    Free text field to be used when code is not availableFree text
    treeblank treeblank treeblank treetree folder Method
    		1 … 1
    prsb03-dataelement-23773link
    The technique or method by which the medication is to be administered.
    treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-23774link
    The coded value for methodSNOMED CT : - ^999000041000001103 | ePrescribing method simple reference set (foundation metadata concept) |
    treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-23775link
    Free text field to be used if no coded text available
    treeblank treeblank treeblank treetree draft  Supply type
    		1 … 1
    prsb03-dataelement-23776link
    A description of the type of supply (e.g. emergency supply, over the counter medication, patient group direction etc)
    treeblank treeblank treeblank treetree folder Batch number
    		1 … 1
    prsb03-dataelement-23778link
    The batch number of the product.
    treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-23779link
    The coded value for the batch numberFMD code : - Derived from Falsified medicines directive
    treeblank treeblank treeblank treeblank treetree draft  Free text
    		1 … 1
    prsb03-dataelement-23780link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treeblank treetree folder Structured dose direction cluster
    		1 … 1
    prsb03-dataelement-23785link
    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.
    treeblank treeblank treeblank treeblank treetree draft  Dose type
    		1 … 1
    prsb03-dataelement-23786link
    The kind of rate or dose specified Calculated or ordered
    treeblank treeblank treeblank treeblank treetree draft  Structured dose direction
    		1 … 1
    prsb03-dataelement-23787link
    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.As per FHIR Dose Syntax Implementation Guidance (NHS Digital): https://developer.nhs.uk/apis/dose-syntax-implementation/
    treeblank treeblank treeblank treeblank treetree folder Structured dose amount
    		1 … 1
    prsb03-dataelement-23788link
    A structural representation of dose amount, e.g. 20mg or 2 tablets. This element will generally only be used when persisting data within systems with 'parsable dose directions' being used to exchange the same information between systems. As per FHIR Dose Syntax Implementation Guidance (NHS Digital): https://simplifier.net/guide/DoseSyntaxImplementationGuidanceforFHIRR4/Home
    treeblank treeblank treeblank treeblank treeblank treetree draft  Dose
    		1 … 1
    prsb03-dataelement-23789link
    Amount of dose medication .Note that this specifies the quantity of the specified medication, not the quantity for each active ingredient(s). Each ingredient amount can be communicated in the Medication resource. For example, if one wants to communicate that a tablet was 375 mg, where the dose was one tablet, you can use the Medication resource to document that the tablet was comprised of 375 mg of drug XYZ. Alternatively if the dose was 375 mg, then you may only need to use the Medication resource to indicate this was a tablet. If the example were an IV such as dopamine and you wanted to communicate that 400mg of dopamine was mixed in 500 ml of some IV solution, then this would all be communicated in the Medication resource. If the administration is not intended to be instantaneous (rate is present or timing has a duration), this can be specified to convey the total amount to be administered over the period of time as indicated by the schedule e.g. 500 ml in dose, with timing used to convey that this should be done over 4 hours.Numeric
    treeblank treeblank treeblank treeblank treeblank treetree draft  Rate
    		1 … 1
    prsb03-dataelement-23790link
    Amount of medication per unit of time. Identifies the speed with which the medication was or will be introduced into the patient. Typically the rate for an infusion e.g. 100 ml per 1 hour or 100 ml/hr. May also be expressed as a rate per unit of time e.g. 500 ml per 2 hours. Other examples: 200 mcg/min or 200 mcg/1 minute; 1 liter/8 hours. Sometimes, a rate can imply duration when expressed as total volume / duration (e.g. 500mL/2 hours implies a duration of 2 hours). However, when rate doesn't imply duration (e.g. 250mL/hour), then the timing.repeat.duration is needed to convey the infuse over time period.Numeric
    treeblank treeblank treeblank treeblank treetree draft  Structured dose timing
    		1 … 1
    prsb03-dataelement-23791link
    A slot containing a structural, computable representation of dose timing and maximum dose. This element will generally only be used when persisting data within systems with 'parsable dose directions' being used to exchange the same information between systems. As per FHIR Dose Syntax Implementation Guidance (NHS Digital): https://simplifier.net/guide/DoseSyntaxImplementationGuidanceforFHIRR4/Home Numeric
    treeblank treeblank treeblank treeblank treetree draft  Dose direction duration
    		1 … 1
    prsb03-dataelement-23792link
    Recommendation of the time period for which the medication should be continued, including direction not to discontinue. As per FHIR Dose Syntax Implementation Guidance (NHS Digital): https://simplifier.net/guide/DoseSyntaxImplementationGuidanceforFHIRR4/Home Numeric
    treeblank treeblank treeblank treeblank treetree draft  Dose directions description
    		1 … 1
    prsb03-dataelement-23793link
    Describes the entire medication dosage and administration directions including dose quantity and medication frequency and optionally duration e.g. “1 tablet at night" or “2mg at 10pm”.Free text
    treeblank treeblank treeblank treeblank treetree draft  Maxdoseperperiod
    		1 … 1
    prsb03-dataelement-23794link
    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.Numeric
    treeblank treeblank treeblank treeblank treetree draft  Maxdoseperadministration
    		1 … 1
    prsb03-dataelement-23795link
    The maximum total quantity of a therapeutic substance that may be administered to a subject per administration.Numeric
    treeblank treeblank treeblank treetree draft  Additional instructions
    		0 … 1
    prsb03-dataelement-23799link
    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.FHIR value set : - Additional instruction
    treeblank treetree folder Procedures and therapies
    		0 … *
    prsb03-dataelement-23856link
    The details of any procedures performed. Includes both psychological and medical therapies and procedures (e.g. cognitive behaviour therapy, hip replacement)
    treeblank treeblank treetree folder Procedure record entry
    		1 … 1
    prsb03-dataelement-23857link
    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.
    treeblank treeblank treeblank treetree folder Procedure
    		1 … 1
    prsb03-dataelement-23872link
    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.
    treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-23873link
    The procedure code.SNOMED CT : - <<71388002 |Procedure| OR <<129125009 |Procedure with explicit context|
    treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-23874link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treeblank treetree folder Anatomical site
    		1 … 1
    prsb03-dataelement-23875link
    The body site of the procedure
    treeblank treeblank treeblank treeblank treetree draft  Coded value
    		1 … 1
    prsb03-dataelement-23876link
    The coded value of the anatomical site.SNOMED CT :- <123037004 |Body structure (body structure)|
    treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-23877link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treeblank treetree folder Laterality
    		0 … 1
    prsb03-dataelement-23878link
    Laterality of the procedure
    treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-23879link
    The coded value for laterality.SNOMED CT:- <182353008 |Side (qualifier value)|
    treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-23880link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treeblank treetree folder Complications related to procedure
    		0 … *
    prsb03-dataelement-23881link
    Details of any intra-operative complications encountered during the procedure, arising during the person’s stay in the recovery unit or directly attributable to the procedure.
    treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-23882link
    The coded value for complications relating to procedure.SNOMED CT : - <404684003 |Clinical finding (finding)|
    treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-23883link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Information and advice given
    		0 … *
    prsb03-dataelement-23898link
    Information and advice given.
    treeblank treeblank treetree folder Information and advice given
    		1 … 1
    prsb03-dataelement-23899link
    The oral or written 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 ‘information prescription'. State here if there are concerns about the extent to which the person and/or carer understand the information provided about diagnosis, prognosis and treatment.
    treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-23900link
    The coded value for information and advice given.SNOMED CT.
    treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-23901link
    Free text field to be used if no code is availableFree text
    treeblank treetree folder Investigations requested
    		0 … *
    prsb03-dataelement-23920link
    Details of any investigations requested
    treeblank treeblank treetree folder Investigations requested record entry
    		1 … 1
    prsb03-dataelement-23921link
    This is an investigation requested record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
    treeblank treeblank treeblank treetree folder Investigation requested
    		1 … 1
    prsb03-dataelement-23935link
    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)
    treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-23936link
    The coded value for Investigation requestedSNOMED CT: - <71388002 |Procedure (procedure)|
    treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-23937link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treeblank treetree draft  Status of request
    		0 … 1
    prsb03-dataelement-23938link
    The status of the investigation request.Code : - draft | active | suspended | completed | entered-in-error | cancelled
    treeblank treeblank treeblank treetree draft  Reason for request
    		0 … 1
    prsb03-dataelement-23939link
    An explanation or justification for why this investigation is being requested.Free text
    treeblank treeblank treeblank treetree draft  Request priority
    		0 … 1
    prsb03-dataelement-23940link
    The urgency of the investigation requested.Code : - routine | urgent | asap | stat
    treeblank treetree folder Plan and requested actions
    		0 … *
    prsb03-dataelement-23956link
    The details of planned investigations, procedures and treatment, and whether this plan has been agreed with the person or their legitimate representative.
    treeblank treeblank treetree folder Plan and requested actions record entry
    		1 … 1
    prsb03-dataelement-23957link
    This is a plan and requested actions record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
    treeblank treeblank treeblank treetree draft  Actions
    		0 … 1
    prsb03-dataelement-23971link
    Including planned investigations, procedures, Interventions and treatment for a patient’s identified conditions and priorities. For each action the following should be identified: a) person responsible - name and designation / department / hospital / patient etc or role (eg GP) responsible for carrying out the proposed action, and where action should take place.b) status - requested, planned or completed. c) When action requested for - requested date, time, or period - as relevant. d) suggested strategies - suggested strategies for potential problems. e) outcome expectations, including patient’s expectations.Free text
    treeblank treeblank treeblank treetree draft  Actions for professionals
    		0 … 1
    prsb03-dataelement-23972link
    Including planned investigations, procedures and treatment for a person's identified conditions and priorities. For each action the following should be identified:outcome expectations, including the person’s expectations. A record of the planned and requested actions. May be structured (table), with actions, names, dates, status, location, strategies.Free text
    treeblank treeblank treeblank treetree draft  Actions for person or their carer
    		0 … 1
    prsb03-dataelement-23973link
    For each action the following should be identified:outcome expectations, including person’s expectations. A record of the planned and requested actions. May be structured (table), with actions, names, dates, status, location, strategies.Free text
    treeblank treeblank treeblank treetree draft  Agreed with the person or their legitimate representative
    		0 … 1
    prsb03-dataelement-23974link
    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.Free text
    treeblank treetree folder Future appointments
    		0 … *
    prsb03-dataelement-23991link
    Details of future appointments.
    treeblank treeblank treetree folder Future appointments record entry
    		1 … 1
    prsb03-dataelement-23992link
    This is the future appointments record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.
    treeblank treeblank treeblank treetree draft  Date of appointment
    		1 … 1
    prsb03-dataelement-23993link
    Date and time of future appointment.Date and time
    treeblank treeblank treeblank treetree draft  Appointment status
    		1 … 1
    prsb03-dataelement-23994link
    The status of the appointment e.g. proposed, booked, confirmed, rejected.Free text
    treeblank treeblank treeblank treetree draft  Reason for appointment
    		1 … 1
    prsb03-dataelement-23995link
    Reason this appointment is scheduled e.g. diagnosis, investigation, treatment or assessmentFree text
    treeblank treeblank treeblank treetree draft  Clinical urgency of appointment
    		0 … 1
    prsb03-dataelement-23997link
    Urgency of appointment.NHS data dictionary : - Priority
    treeblank treeblank treeblank treetree folder Location of future appointment
    		0 … 1
    prsb03-dataelement-23998link
    The location of the appointment.
    treeblank treeblank treeblank treeblank treetree draft  Coded value
    		0 … 1
    prsb03-dataelement-23999link
    The coded value for locationNHS data dictionary : - Organisation data service
    treeblank treeblank treeblank treeblank treetree draft  Free text
    		0 … 1
    prsb03-dataelement-24000link
    Free text field to be used if no code is availableFree text
    treeblank treeblank treeblank treetree draft  Specialty
    		0 … 1
    prsb03-dataelement-24001link
    The specialty e.g. physiotherapy, oncology, mental health etc. NHS data dictionary :- Activity treatment function code
    treeblank treeblank treeblank treetree draft  Service
    		0 … 1
    prsb03-dataelement-24002link
    The service being provided.SNOMED CT: - 1127531000000102 |Services simple reference set (foundation metadata concept)|
    treeblank treeblank treeblank treetree folder Professional to see the person
    		0 … 1
    prsb03-dataelement-24003link
    The name and role of the professional e.g. consultant, care worker, nurse consultant.
    treeblank treeblank treeblank treeblank treetree draft  Name
    		0 … 1
    prsb03-dataelement-24004link
    The name of the professional seeing the person.Free text
    treeblank treeblank treeblank treeblank treetree draft  Role
    		0 … 1
    prsb03-dataelement-24005link
    The role of the professional seeing the person.FHIR values set : - ukcorepractitionerrolecode
    treeblank treetree folder Consent
    		1 … 1
    prsb03-dataelement-23952link
    Legal information captured relating to patient care, such as consent.
    treeblank treeblank treetree draft  Consent relating to child
    		0 … 1
    prsb03-dataelement-23953link
    Consideration of age and competency, applying Gillick competency or Fraser guidelines. Record of person with parental responsibility or appointed guardian where child lacks competency. Record if there is disagreement between patient and parent.Free text
    treeblank treeblank treetree draft  Consent for treatment record
    		1 … 1
    prsb03-dataelement-23955link
    Whether consent has been obtained for the treatment. May include where record of consent is located or record of consent.Free text
    treeblank treetree draft  Deviation from plan
    		0 … *
    prsb03-dataelement-24006link

    Rationale for variation from the plan
    treetree folder Wound care episode outcome
    		1 … 1
    prsb03-dataelement-25880link

    Recorded outcome of the wound care episode, based on the existing clinical summary data concept

    treeblank treetree folder Clinical Summary
    		0 … 1
    prsb03-dataelement-25881link
    Clinical Summary
    treeblank treeblank treetree draft  Clinical summary
    		0 … 1
    prsb03-dataelement-25886link
    Summary of the encounter. Where possible, very brief. This may include interpretation of findings and results; differential diagnoses, opinion and specific action(s). Planned actions will be recorded under ‘plan’.Free text
    treeblank treeblank treetree draft  Treatments and interventions and changes made to treatments.
    		1 … *
    prsb03-dataelement-25905link
    The relevant treatments and interventions which the patient received during the inpatient stay. Include psychological therapies. All medications should be recorded under the medications section.Free text