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draft Transaction Personal details 2.16.840.1.113883.3.1937.777.28.4.434

Data Set PRSB Record structure and content 2.16.840.1.113883.3.1937.777.28.1.1

Name Id
draft Personal details 2.16.840.1.113883.3.1937.777.28.4.434
Version / effective date Expiration date
2022‑10‑31 13:33:19
Description
Name Details [‑]
folder draft Person demographics 1 … 1
prsb03-dataelement-10868
Id prsb03-dataelement-10868 (2019‑03‑27 19:02:25)
Cardinality 1 … 1
Description The person's details and contact information.

Properties

Information Type Record
target Used by one transaction, 0 templates, inherited once
 
folder draft Person name 1 … 1
prsb03-dataelement-10869
Id prsb03-dataelement-10869 (2019‑03‑27 19:05:18) 1
Cardinality 1 … 1
Description Details of the person's name
Relationship
target Used by one transaction, 0 templates, inherited once
 
draft Person first name 1 … 1
prsb03-dataelement-13799
Id prsb03-dataelement-13799 (2020‑11‑09 16:09:39)
Cardinality 1 … 1
Description The first name(s) of the person. This includes middle names.
Rationale Patient.name.given
Operationalization NHS data dictionary :- Person given name
Value Domain
Property
max length
35
target Used by one transaction, 0 templates, inherited once
 
draft Person family name 1 … 1
prsb03-dataelement-13800
Id prsb03-dataelement-13800 (2020‑11‑09 16:43:41)
Cardinality 1 … 1
Description The family name or surname of the person
Rationale Patient.name.family
Operationalization NHS data dictionary : - Person family name

Value Domain
Property
max length
35
target Used by one transaction, 0 templates, inherited once
 
draft Person preferred name 0 … 1
prsb03-dataelement-10870
Id prsb03-dataelement-10870 (2019‑03‑27 19:06:43)
Cardinality 0 … 1
Description The name by which a person wishes to be addressed. The preferred name volunteered by the person or a preferred name given by PDS that the person has asked to be called by.
Relationship
Rationale Patient.name
Operationalization NHS data dictionary: - Person full name
Value Domain
Property
max length
70
target Used by one transaction, 0 templates, inherited once
 
draft Title 0 … 1
prsb03-dataelement-13089
Id prsb03-dataelement-13089 (2020‑06‑04 17:22:32) 0.1
Cardinality 0 … 1
Description Person's title
Rationale Patient.name.prefix
Operationalization NHS data dictionary: - Person Title
Value Domain
Property
max length
35
target Used by one transaction, 0 templates, inherited once
 
draft Person name suffix 0 … 1
prsb03-dataelement-13798
Id prsb03-dataelement-13798 (2020‑11‑08 22:52:48)
Cardinality 0 … 1
Description A textual suffix that may be added to the end of a PERSON's name, for example, OBE, MBE, BSc, JP, GM
Rationale Patient.name.suffix
Operationalization NHS data dictionary: - Person suffix
Value Domain
Property
max length
35
target Used by one transaction, 0 templates, inherited once
 
draft Person full name 0 … 1
prsb03-dataelement-13801
Id prsb03-dataelement-13801 (2020‑11‑09 17:03:29)
Cardinality 0 … 1
Description The full name of the person in text representation.
Rationale Patient.name.text
Operationalization NHS data dictionary :- Person full name
Value Domain
Property
max length
70
target Used by one transaction, 0 templates, inherited 6 times
 
draft Date of birth 1 … 1
prsb03-dataelement-10871
Id prsb03-dataelement-10871 (2019‑03‑27 19:08:01) 1
Cardinality 1 … 1
Description The date of birth of the person.

Properties

FHIR Patient.birthDate
Relationship
Rationale Patient.birthdate
Source NHS NSS : - https://www.ndc.scot.nhs.uk/Dictionary-A-Z/Definitions/index.asp?Search=D&ID=186&Title=Date%20of%20Birth
Operationalization NHS data dictionary:- Person birth date
Value Domain
Property
Timestamp precision
day, month and year
target Used by one transaction, 0 templates, inherited once
 
draft Gender 0 … 1
prsb03-dataelement-10872
Id prsb03-dataelement-10872 (2019‑03‑27 19:08:52) 1
Cardinality 0 … 1
Description The person's stated gender.

Properties

FHIR Patient.gender
Relationship
Rationale Patient.gender
Source NHS Wales : - https://fhir.standards.wales/CodeSystem/GenderIdentity
Operationalization NHS data dictionary :- Person stated gender code

Value Domain
Property
max length
1
target Used by one transaction, 0 templates, inherited once
 
draft Person alias 0 … *
prsb03-dataelement-10873
Id prsb03-dataelement-10873 (2019‑03‑27 19:10:48) 1
Cardinality 0 … *
Description Other name(s) associated with the person.
Relationship
Operationalization Free text
Value Domain
Property
max length
70
target Used by one transaction, 0 templates, inherited once
 
draft Ethnicity 0 … 1
prsb03-dataelement-10874
Id prsb03-dataelement-10874 (2019‑03‑27 19:11:37) 1
Cardinality 0 … 1
Description The ethnicity of the person as specified by the person.
Relationship
Rationale Patient.extension(ethnicCategory)
Source

NHS_Wales: http://www.datadictionary.wales.nhs.uk/index.html#!WordDocuments/ethnicgroup.htm

NHS_NSS: https://www.ndc.scot.nhs.uk/Dictionary-A-Z/Definitions/index.asp?Search=E&ID=243&Title=Ethnic%20Group

Operationalization NHS data dictionary :- Ethnic category
Value Domain
Property
max length
2
target Used by one transaction, 0 templates, inherited once
 
draft Religion 0 … 1
prsb03-dataelement-10876
Id prsb03-dataelement-10876 (2019‑03‑27 19:15:05) 1
Cardinality 0 … 1
Description The religious affiliation as specified by the person.
Relationship
Rationale Patient.extension(religiousAffiliation)
Source NHS NSS: - https://www.ndc.scot.nhs.uk/Dictionary-A-Z/Definitions/index.asp?Search=R&ID=795&Title=Religion
Operationalization
SNOMED_CT:- Religion

Value Domain
target Used by one transaction, 0 templates, inherited once
 
draft Sex 0 … 1
prsb03-dataelement-10877
Id prsb03-dataelement-10877 (2019‑03‑27 19:15:45) 1
Cardinality 0 … 1
notice There is an open issue with this item:
Description The person’s phenotypic sex. Determines how the person will be treated clinically.
Relationship
Operationalization NHS data dictionary: - person phenotypic sex
Value Domain
Property
max length
1
target Used by one transaction, 0 templates, inherited once
 
draft Carer Status 0 … 1
prsb03-dataelement-21924
Id prsb03-dataelement-21924 (2021‑12‑16 18:10:29)
Cardinality 0 … 1
Description The carer status is important to ensure provision is put in place to support the person receiving and providing care.
Source Snomed CT Subject is carer (findings)

https://termbrowser.nhs.uk/?perspective=full&conceptId1=1127521000000104&edition=uk-edition&release=v20211124&server=https://termbrowser.nhs.uk/sct-browser-api/snomed&langRefset=999001261000000100,999000691000001104 



Snomed CT Person themselves is a carer (finding)

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

Operationalization 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

Value Domain
target Used by one transaction, 0 templates, inherited 0 times
 
draft NHS number 0 … 1
prsb03-dataelement-10879
Id prsb03-dataelement-10879 (2019‑03‑27 19:16:57) 1
Cardinality 0 … 1
Description The unique identifier for a person within the NHS in England and Wales.

Properties

FHIR Patient.identifier.nhsnumber
Relationship
Rationale Patient.identifier(nhsnumber)
Operationalization NHS data dictionary:- NHS number
Value Domain
Property
max length
10
target Used by one transaction, 0 templates, inherited once
 
draft Other identifier 0 … *
prsb03-dataelement-10880
Id prsb03-dataelement-10880 (2019‑03‑27 19:18:59)
Cardinality 0 … *
Description Country specific or local identifier, e.g. Community Health Index (CHI) in Scotland.
Relationship
Rationale Patient.identifier
Operationalization
Value Domain
Property
max length
20
target Used by one transaction, 0 templates, inherited once
 
folder draft Person's address 1 … *
prsb03-dataelement-10881
Id prsb03-dataelement-10881 (2019‑03‑27 19:19:27)
Cardinality 1 … *
Description Person’s usual place of residence, and where relevant temporary and correspondence addresses.

Properties

FHIR Patient.Address
Relationship
target Used by one transaction, 0 templates, inherited once
 
draft Address line 1 1 … 1
prsb03-dataelement-13082
Id prsb03-dataelement-13082 (2020‑05‑29 15:28:51)
Cardinality 1 … 1
Description Person's first line of address.
Rationale Patient.address.line
Operationalization
NHS data dictionary :-  Address line 1

Value Domain
Property
max length
35
target Used by one transaction, 0 templates, inherited once
 
draft Address line 2 0 … 1
prsb03-dataelement-13083
Id prsb03-dataelement-13083 (2020‑05‑29 15:32:41)
Cardinality 0 … 1
Description Person's second line of address.
Rationale Patient.address.city
Operationalization
NHS data dictionary :- Address line 2

Value Domain
Property
max length
35
target Used by one transaction, 0 templates, inherited once
 
draft Address line 3 0 … 1
prsb03-dataelement-13084
Id prsb03-dataelement-13084 (2020‑05‑29 15:35:34)
Cardinality 0 … 1
Description Person's third line of address.
Rationale Patient.address.district
Operationalization
NHS data dictionary : - Address line 3
Value Domain
Property
max length
35
target Used by one transaction, 0 templates, inherited once
 
draft Address line 4 0 … 1
prsb03-dataelement-13085
Id prsb03-dataelement-13085 (2020‑06‑01 11:29:56)
Cardinality 0 … 1
Description Person's fourth line of address.
Rationale Patient.address.state
Operationalization
NHS data dictionary : - Address line 4

Value Domain
Property
max length
35
target Used by one transaction, 0 templates, inherited once
 
draft Address line 5 0 … 1
prsb03-dataelement-13086
Id prsb03-dataelement-13086 (2020‑06‑01 11:32:10)
Cardinality 0 … 1
Description Person's fifth line of address.
Rationale Patient.address.country
Operationalization NHS data dictionary : - Address line 5

Value Domain
Property
max length
35
target Used by one transaction, 0 templates, inherited once
 
draft Postcode 1 … 1
prsb03-dataelement-13087
Id prsb03-dataelement-13087 (2020‑06‑01 11:40:09)
Cardinality 1 … 1
Description The person's postcode.
Rationale Patient.address.postalcode
Operationalization NHS data dictionary :- Postcode of usual address

Value Domain
Property
max length
8
target Used by one transaction, 0 templates, inherited once
 
draft Address type 0 … 1
prsb03-dataelement-13221
Id prsb03-dataelement-13221 (2020‑07‑08 15:58:39)
Cardinality 0 … 1
Description The type of address e.g. Main address, Temp address
Rationale Patient.address.use
Operationalization NHS data dictionary :- Address Association Type
Value Domain
Property
max length
1
target Used by one transaction, 0 templates, inherited once
 
folder draft Person's contact details 0 … 1
prsb03-dataelement-13804
Id prsb03-dataelement-13804 (2020‑11‑25 18:32:36)
Cardinality 0 … 1
Description Details of the person's contact information.
target Used by one transaction, 0 templates, inherited once
 
draft Preferred contact method 0 … 1
prsb03-dataelement-10886
Id prsb03-dataelement-10886 (2019‑03‑27 19:29:17)
Cardinality 0 … 1
Description Preferred contact method, e.g. email, letter, phone, text message etc.
Relationship
Operationalization NHS data dictionary:- Preferred Contact Method
Value Domain
Property
max length
1
target Used by one transaction, 0 templates, inherited 2 times
 
folder draft Person's telephone number details 0 … *
prsb03-dataelement-10883
Id prsb03-dataelement-10883 (2019‑03‑27 19:22:39)
Cardinality 0 … *
Description The person's telephone number details

Properties

FHIR Patient.telecom
Relationship
target Used by one transaction, 0 templates, inherited once
 
draft Person's telephone number 0 … 1
prsb03-dataelement-13808
Id prsb03-dataelement-13808 (2020‑11‑26 16:51:24)
Cardinality 0 … 1
Description The person's telephone number
Rationale Patient.contact.telecon.value
Operationalization NHS data dictionary : - UK telephone number
Value Domain
Property
max length
35
target Used by one transaction, 0 templates, inherited 2 times
 
draft Person's telephone number type 0 … 1
prsb03-dataelement-13805
Id prsb03-dataelement-13805 (2020‑11‑25 18:37:54)
Cardinality 0 … 1
Description The contact type e.g. home, mobile
Rationale Patient.telecon.use
Operationalization FHIR value set: - Contact point use
Value Domain
Property
max length
6
Example Home
Example Mobile
Example Temp
Example Old
Example Work
target Used by one transaction, 0 templates, inherited once
 
draft Preference of telephone number 0 … 1
prsb03-dataelement-13809
Id prsb03-dataelement-13809 (2020‑11‑26 16:55:09)
Cardinality 0 … 1
Description The preferred order of use for the telephone number
Rationale Patient.telecom.rank
Operationalization Preference of use 1-5, 1 being the highest.
Value Domain
target Used by one transaction, 0 templates, inherited once
 
folder draft Person's email address details 0 … *
prsb03-dataelement-13807
Id prsb03-dataelement-13807 (2020‑11‑26 16:29:22)
Cardinality 0 … *
Description Details of the person's email address
target Used by one transaction, 0 templates, inherited once
 
draft Person's email address 0 … 1
prsb03-dataelement-10882
Id prsb03-dataelement-10882 (2019‑03‑27 19:20:19)
Cardinality 0 … 1
Description Email address of the person.

Properties

FHIR Patient.telecom
Relationship
Rationale Patient.contact.telecon.value
Operationalization NHS data dictionary:- Contact Email Address
Value Domain
Property
max length
255
target Used by one transaction, 0 templates, inherited once
 
draft Person's email address type 0 … 1
prsb03-dataelement-13811
Id prsb03-dataelement-13811 (2020‑11‑26 17:30:54)
Cardinality 0 … 1
Description
The type of email address, home, work.
Rationale Patient.telecon.use
Operationalization FHIR value set: - Contact point use
Value Domain
Property
max length
6
Example Home
Example Work
Example old
target Used by one transaction, 0 templates, inherited once
 
draft Preference of email address 0 … 1
prsb03-dataelement-13810
Id prsb03-dataelement-13810 (2020‑11‑26 17:07:11)
Cardinality 0 … 1
Description The preferred order of use of email address
Rationale Patient.telecon.rank
Operationalization Preference of use 1-5, 1 being the highest.
Value Domain
target Used by one transaction, 0 templates, inherited once
 
draft Other contact information 0 … *
prsb03-dataelement-13806
Id prsb03-dataelement-13806 (2020‑11‑26 16:07:06)
Cardinality 0 … *
Description
Contact details via fax, sms, url.
Rationale Patient.contact.telecon.value
Operationalization NHS data dictionary:- Communication contact string
Value Domain
Property
max length
255
target Used by one transaction, 0 templates, inherited once
 
draft Photograph 0 … 1
prsb03-dataelement-13065
Id prsb03-dataelement-13065 (2020‑05‑15 16:50:49)
Cardinality 0 … 1
Description A photograph of the person for identification and to show what the person looks like normally.
Rationale Patient.photo
Operationalization Mulitmedia file
Value Domain
target Used by one transaction, 0 templates, inherited once
 
draft Place of birth 0 … 1
prsb03-dataelement-10884
Id prsb03-dataelement-10884 (2019‑03‑27 19:25:07)
Cardinality 0 … 1
Description The country of birth of the person.
Relationship
Rationale Patient.extension(Birthplace)
Operationalization NHS data dictionary :- Country code (birth)
Value Domain
Property
max length
3
target Used by one transaction, 0 templates, inherited once
 
draft Marital status 0 … 1
prsb03-dataelement-10885
Id prsb03-dataelement-10885 (2019‑03‑27 19:25:57)
Cardinality 0 … 1
Description An indicator to identify the legal marital status of the person.
Relationship
Rationale Patient.maritalstatus
Operationalization NHS data dictionary :- Person marital status
Value Domain
Property
max length
1
target Used by one transaction, 0 templates, inherited once
 
folder draft About me 0 … 1
prsb03-dataelement-466
Id prsb03-dataelement-466 (2018‑10‑31)
Cardinality 0 … 1
Description About me

Properties

Information Type Record
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft What is most important to me 0 … 1
prsb03-dataelement-12964
Id prsb03-dataelement-12964 (2020‑03‑30 10:50:29) 0.3
Cardinality 0 … 1
Description A description of what is most important to you.
Source SNOMED CT Tag : -  363882003 | Motivation (observable entity) |

target Used by one transaction, 0 templates, inherited 0 times
 
draft What is most important to me 0 … 1
prsb03-dataelement-14325
Id prsb03-dataelement-14325 (2021‑07‑01 13:49:23)
Cardinality 0 … 1
Description 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, volunteering
Operationalization Free text
Value Domain
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft People who are important to me 0 … 1
prsb03-dataelement-13009
Id prsb03-dataelement-13009 (2020‑04‑27 11:23:17) 0.3
Cardinality 0 … 1
Description Details of who is important to you and why. 
Source SNOMED CT Tag: - 302160007 | Household, family and support network detail (observable entity) |

target Used by one transaction, 0 templates, inherited 0 times
 
draft People who are important to me 0 … 1
prsb03-dataelement-14327
Id prsb03-dataelement-14327 (2021‑07‑01 16:27:25)
Cardinality 0 … 1
Description 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 say
Operationalization Free text 
Value Domain
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft How I communicate and how to communicate with me 0 … 1
prsb03-dataelement-13006
Id prsb03-dataelement-13006 (2020‑04‑24 11:48:24) 0.3
Cardinality 0 … 1
Description A description of how you communicate normally. 
Source SNOMED CT Tag : - 428330008 | Preferred mode of communication (observable entity) |
target Used by one transaction, 0 templates, inherited 0 times
 
draft How I communicate and how to communicate with me 0 … 1
prsb03-dataelement-14329
Id prsb03-dataelement-14329 (2021‑07‑01 16:39:25)
Cardinality 0 … 1
Description

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.

Operationalization Free text
Value Domain
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft My wellness 0 … 1
prsb03-dataelement-13005
Id prsb03-dataelement-13005 (2020‑04‑24 11:45:53)
Cardinality 0 … 1
Synonym
0.3
Description A description covering what you are able to do, how you engage with others and how you feel on a typical day through to on a day when you are unwell or really unwell.
Source SNOMED CT Tag : - 363800008 | General wellbeing (observable entity) |
target Used by one transaction, 0 templates, inherited 0 times
 
draft My wellness 0 … 1
prsb03-dataelement-14331
Id prsb03-dataelement-14331 (2021‑07‑01 16:58:12)
Cardinality 0 … 1
Description

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

  • 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
    Operationalization Free text
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Please do and please don't 0 … 1
    prsb03-dataelement-13008
    Id prsb03-dataelement-13008 (2020‑04‑27 10:34:59) 0.3
    Cardinality 0 … 1
    Description A description of things you want someone supporting you to do (or not to do). 
    Source SNOMED CT Tag : - 414642003 | Making considered choices (observable entity) |
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Please do and please don't 0 … 1
    prsb03-dataelement-14333
    Id prsb03-dataelement-14333 (2021‑07‑01 17:26:02)
    Cardinality 0 … 1
    Description 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.
    Operationalization Free text
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft How and when to support me 0 … 1
    prsb03-dataelement-13007
    Id prsb03-dataelement-13007 (2020‑04‑27 10:29:54) 0.3
    Cardinality 0 … 1
    Description A description of how and when you want someone caring for you to support you.
    Source SNOMED CT Tag: -  1364521000000106 |Trigger factor to activate care plan (observable entity)|
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft How and when to support me 0 … 1
    prsb03-dataelement-14335
    Id prsb03-dataelement-14335 (2021‑07‑01 17:35:20)
    Cardinality 0 … 1
    Description

    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.

    Operationalization Free text
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Also worth knowing about me 0 … 1
    prsb03-dataelement-13094
    Id prsb03-dataelement-13094 (2020‑06‑22 11:30:09) 0.2
    Cardinality 0 … 1
    Description A description of what is also worth knowing about you for people caring or supporting you. 
    Source SNOMED CT Tag: - 160476009 | Social / personal history observable (observable entity) |

    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Also worth knowing about me 0 … 1
    prsb03-dataelement-14337
    Id prsb03-dataelement-14337 (2021‑07‑01 17:41:50)
    Cardinality 0 … 1
    Description

    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.

    Operationalization Free text
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Supported to write this by 0 … 1
    prsb03-dataelement-10368
    Id prsb03-dataelement-10368 (2018‑10‑31)
    Cardinality 0 … 1
    Description 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.
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Location to multimedia file 0 … 1
    prsb03-dataelement-14326
    Id prsb03-dataelement-14326 (2021‑07‑01 13:50:03)
    Cardinality 0 … 1
    Description The link to the person's multimedia file
    Operationalization Link to URL
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Individual requirements 0 … *
    prsb03-dataelement-160
    Id prsb03-dataelement-160 (2018‑10‑31)
    Cardinality 0 … *
    Description The individual requirements of the person.
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Reasonable adjustment 0 … 1
    prsb03-dataelement-12991
    Id prsb03-dataelement-12991 (2020‑04‑23 19:50:39)
    Cardinality 0 … 1
    Description A record of reasonable adjustments that must be provided by the service to comply with the Equality Act 2010.
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Impairment 0 … 1
    prsb03-dataelement-13001
    Id prsb03-dataelement-13001 (2020‑04‑23 20:09:01)
    Cardinality 0 … 1
    Description A record of any impairments for the person relating to reasonable adjustments.
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Impairment record entry 0 … 1
    prsb03-dataelement-13062
    Id prsb03-dataelement-13062 (2020‑05‑12 15:52:51)
    Cardinality 0 … 1
    Description This is an impairment record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items

    Properties

    Information Type Event.Record
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Impairment category 0 … 1
    prsb03-dataelement-13022
    Id prsb03-dataelement-13022 (2020‑04‑28 19:21:25)
    Cardinality 0 … 1
    Description
    The category of the impairment e.g.  Physical disability, Sensory disability - such as sight or hearing, Long-term condition.
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Coded value 0 … 1
    prsb03-dataelement-13507
    Id prsb03-dataelement-13507 (2020‑09‑02 18:45:17)
    Cardinality 0 … 1
    Description The coded value for impairment.
    Operationalization SNOMED CT
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Free text 0 … 1
    prsb03-dataelement-13508
    Id prsb03-dataelement-13508 (2020‑09‑02 18:46:00)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
    Description Free text field to be used if no code is available
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Impairment additional detail 0 … 1
    prsb03-dataelement-13023
    Id prsb03-dataelement-13023 (2020‑04‑28 19:23:16)
    Cardinality 0 … 1
    Description

    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).
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Cognition 0 … 1
    prsb03-dataelement-10066
    Id prsb03-dataelement-10066 (2018‑10‑31)
    Cardinality 0 … 1
    Description Details of the persons cognitive impairment.

    Properties

    Information Type Event.Record
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Cognition 0 … 1
    prsb03-dataelement-13669
    Id prsb03-dataelement-13669 (2020‑09‑08 22:42:26)
    Cardinality 0 … 1
    Description The cognitive impairment to be considered when communicating with the person, child or their primary carer.
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Mobility 0 … 1
    prsb03-dataelement-10067
    Id prsb03-dataelement-10067 (2018‑10‑31)
    Cardinality 0 … 1
    Description Details of the person's mobility needs.

    Properties

    Information Type Event.Record
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Mobility needs 0 … 1
    prsb03-dataelement-13670
    Id prsb03-dataelement-13670 (2020‑09‑08 22:45:14)
    Cardinality 0 … 1
    Description The mobility needs of the person that allows movement between two spaces and achieves participation and a degree of independence.
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Coded value 0 … 1
    prsb03-dataelement-13671
    Id prsb03-dataelement-13671 (2020‑09‑08 22:47:06)
    Cardinality 0 … 1
    Description The coded value for mobility needs
    Operationalization SNOMED CT: - ^999002551000000108 |Mobility findings simple reference set (foundation metadata concept)|
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Free text 0 … 1
    prsb03-dataelement-13672
    Id prsb03-dataelement-13672 (2020‑09‑08 22:47:50)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
    Description Free text field to be used if no code is available
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Other individual requirements 0 … 1
    prsb03-dataelement-10835
    Id prsb03-dataelement-10835 (2019‑03‑22 16:24:41)
    Cardinality 0 … 1
    Description
    Details of any other individual requirements the person may have.

    Properties

    Information Type Event.Record
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Other individual requirement 0 … 1
    prsb03-dataelement-13673
    Id prsb03-dataelement-13673 (2020‑09‑08 22:51:48)
    Cardinality 0 … 1
    Description Other individual requirements that a person may have.
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Alerts 0 … *
    prsb03-dataelement-10741
    Id prsb03-dataelement-10741 (2019‑03‑06 17:55:12)
    Cardinality 0 … *
    Description Details of alerts.
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Alerts record entry 0 … 1
    prsb03-dataelement-10916
    Id prsb03-dataelement-10916 (2019‑04‑09 12:53:12)
    Cardinality 0 … 1
    Description This is an alerts record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items

    Properties

    Information Type Event.Record
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Location of alert 0 … 1
    prsb03-dataelement-10756
    Id prsb03-dataelement-10756 (2019‑03‑07 18:40:55)
    Cardinality 0 … 1
    Description The organisation raising the alert.
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Coded value 0 … 1
    prsb03-dataelement-13568
    Id prsb03-dataelement-13568 (2020‑09‑07 12:15:55)
    Cardinality 0 … 1
    Description The coded value of location
    Operationalization NHS data dictionary: - Organisation data service
    Value Domain
    Property
    min length max length
    3 5
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Free text 0 … 1
    prsb03-dataelement-13569
    Id prsb03-dataelement-13569 (2020‑09‑07 12:19:02)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
    Description Free text field to be used if no code is available
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Alert 0 … 1
    prsb03-dataelement-10742
    Id prsb03-dataelement-10742 (2019‑03‑06 18:10:58)
    Cardinality 0 … 1
    Description Any significant information meriting a specific and highly visible warning to any user (e.g. metallic implant, potential dangerous pet).
    Operationalization Free text
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Legal information 0 … 1
    prsb03-dataelement-520
    Id prsb03-dataelement-520 (2018‑10‑31)
    Cardinality 0 … 1
    Description The legal information relating to the person.
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Consent for treatment record 0 … 1
    prsb03-dataelement-10420
    Id prsb03-dataelement-10420 (2018‑10‑31)
    Cardinality 0 … 1
    Description Details of the person's consent for treatment.

    Properties

    Information Type Event.Record
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Consent for treatment record 0 … 1
    prsb03-dataelement-13574
    Id prsb03-dataelement-13574 (2020‑09‑07 16:40:51)
    Cardinality 0 … 1
    Description 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.
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Location of document 0 … 1
    prsb03-dataelement-13777
    Id prsb03-dataelement-13777 (2020‑10‑16 16:32:46)
    Cardinality 0 … 1
    Description The location of the consent for treatment record.
    Relationship
    Operationalization Free text or URL
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Consent for information sharing 1 … 1
    prsb03-dataelement-10421
    Id prsb03-dataelement-10421 (2018‑10‑31)
    Cardinality 1 … 1
    Description
    Details of the person's consent for information sharing.

    Properties

    Information Type Event.Record
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Consent for information sharing 1 … 1
    prsb03-dataelement-13575
    Id prsb03-dataelement-13575 (2020‑09‑07 16:47:31)
    Cardinality 1 … 1
    Description This is a record of consent for information sharing under the common law duty of confidentiality. Where consent has not been obtained or sought, the reason why should be provided. Include best interests decision where person lacks capacity. This is a placeholder until the national guidance is published.
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Reason for consent not given 0 … 1
    prsb03-dataelement-13778
    Id prsb03-dataelement-13778 (2020‑10‑16 16:34:53)
    Cardinality 0 … 1
    Description Reason not given for consent
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Consent relating to child 0 … 1
    prsb03-dataelement-10422
    Id prsb03-dataelement-10422 (2018‑10‑31)
    Cardinality 0 … 1
    Description Details of the person's consent relating to child

    Properties

    Information Type Event.Record
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Consent relating to child 0 … 1
    prsb03-dataelement-13576
    Id prsb03-dataelement-13576 (2020‑09‑07 16:50:40)
    Cardinality 0 … 1
    Description The person with parental responsibility or appointed guardian where a child lacks competency. Consideration of age and competency, applying Gillick competency or Fraser guidelines.
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Location of document 0 … 1
    prsb03-dataelement-22489
    Id prsb03-dataelement-22489 (2022‑05‑03 12:58:36)
    Cardinality 0 … 1
    Description The location of the consent document
    Operationalization


    Free text or URL
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Mental capacity assessment 0 … 1
    prsb03-dataelement-10424
    Id prsb03-dataelement-10424 (2018‑10‑31)
    Cardinality 0 … 1
    Description Details of the persons mental capacity assessment

    Properties

    Information Type Event.Record
    target Used by one transaction, 0 templates, inherited 2 times
     
    draft Mental capacity assessment 0 … 1
    prsb03-dataelement-13724
    Id prsb03-dataelement-13724 (2020‑09‑16 11:32:28)
    Cardinality 0 … 1
    Description 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.
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Location of document 0 … 1
    prsb03-dataelement-13779
    Id prsb03-dataelement-13779 (2020‑10‑16 16:40:41)
    Cardinality 0 … 1
    Description The location of the mental capacity assessment information.
    Relationship
    Operationalization Free text or URL
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Lasting power of attorney for health and welfare or court-appointed deputy (or equivalent) 0 … *
    prsb03-dataelement-10425
    Id prsb03-dataelement-10425 (2018‑10‑31)
    Cardinality 0 … *
    Description Details of the person's LPA record or equivalent

    Properties

    Information Type Event.Record

    target Used by one transaction, 0 templates, inherited once
     
    folder draft Lasting power of attorney for health and welfare or court appointed deputy (or equivalent) 0 … 1
    prsb03-dataelement-13634
    Id prsb03-dataelement-13634 (2020‑09‑08 20:05:47)
    Cardinality 0 … 1
    Description Record of one or more people who have been given power (LPA) by the person when they had capacity to make decisions about their health and welfare should they lose capacity to make those decisions. To be valid, an LPA must have been registered with the Court of Protection. If life-sustaining treatment is being 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.
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Coded value 0 … 1
    prsb03-dataelement-13636
    Id prsb03-dataelement-13636 (2020‑09‑08 20:10:08)
    Cardinality 0 … 1
    Description The coded value for the LPA
    Operationalization SNOMED CT: - ^999001951000000107 |Personal welfare lasting power of attorney findings simple reference set (foundation metadata concept)|
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Location of document 0 … 1
    prsb03-dataelement-13776
    Id prsb03-dataelement-13776 (2020‑10‑12 13:50:45)
    Cardinality 0 … 1
    Description The location of the LPA information
    Operationalization Free text or URL
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited once
     
    draft Name of LPA 0 … 1
    prsb03-dataelement-13635
    Id prsb03-dataelement-13635 (2020‑09‑08 20:08:39)
    Cardinality 0 … 1
    Description The names of any appointed people or deputies
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited once
     
    draft Contact details 0 … 1
    prsb03-dataelement-13637
    Id prsb03-dataelement-13637 (2020‑09‑08 20:11:29)
    Cardinality 0 … 1
    Description The contact details of the LPA
    Operationalization NHS data dictionary:- UK telephone number
    Value Domain
    Property
    max length
    35
    target Used by one transaction, 0 templates, inherited once
     
    folder draft Lasting power of attorney for property and financial affairs or court-appointed deputy (or equivalent) 0 … *
    prsb03-dataelement-14949
    Id prsb03-dataelement-14949 (2021‑09‑28 12:06:50)
    Cardinality 0 … *
    Description Details of the person's LPA record or equivalent

    Properties

    Information Type Event.Record

    Relationship
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Lasting power of attorney for property and financial affairs or court appointed deputy (or equivalent) 0 … *
    prsb03-dataelement-14954
    Id prsb03-dataelement-14954 (2021‑09‑28 12:08:18)
    Cardinality 0 … *
    Description Record of one or more people who have been given power (LPA) by the person when they had capacity to make decisions about their property and financial affairs should they lose capacity to make those decisions. To be valid, an LPA must have been registered with the Court of Protection. If life-sustaining treatment 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.
    Relationship
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Coded value 0 … 1
    prsb03-dataelement-14955
    Id prsb03-dataelement-14955 (2021‑09‑28 12:08:18)
    Cardinality 0 … 1
    Description The coded value for the LPA
    Relationship
    Operationalization SNOMED CT: - 341041000000103 | Lasting power of attorney property and affairs (observable entity) |
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Location of document 0 … 1
    prsb03-dataelement-14956
    Id prsb03-dataelement-14956 (2021‑09‑28 12:08:18)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13776 (2020‑10‑12 13:50:45)
    Description The location of the LPA information
    Operationalization Free text or URL
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Name of LPA 0 … 1
    prsb03-dataelement-14957
    Id prsb03-dataelement-14957 (2021‑09‑28 12:08:18)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13635 (2020‑09‑08 20:08:39)
    Description The names of any appointed people or deputies
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Contact details 0 … 1
    prsb03-dataelement-14958
    Id prsb03-dataelement-14958 (2021‑09‑28 12:08:18)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13637 (2020‑09‑08 20:11:29)
    Description The contact details of the LPA
    Operationalization NHS data dictionary:- UK telephone number
    Value Domain
    Property
    max length
    35
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Deprivation of Liberty Safeguards or equivalent 0 … 1
    prsb03-dataelement-10426
    Id prsb03-dataelement-10426 (2018‑10‑31)
    Cardinality 0 … 1
    Description Details of the person's Deprivation of Liberty Safeguards (DoLS) or equivalent

    Properties

    Information Type Event.Record
    target Used by one transaction, 0 templates, inherited once
     
    draft Application date 0 … 1
    prsb03-dataelement-13068
    Id prsb03-dataelement-13068 (2020‑05‑21 18:04:27)
    Cardinality 0 … 1
    Description The date the application was made
    Operationalization Date and time
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Application status 0 … 1
    prsb03-dataelement-13069
    Id prsb03-dataelement-13069 (2020‑05‑21 18:05:36)
    Cardinality 0 … 1
    Description The status of the DOLs application.
    Operationalization Free text : - Requested or authorised
    Value Domain
    Property
    max length
    10
    Example Requested
    Example Authorised
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Deprivation of liberty safeguards or equivalent 0 … 1
    prsb03-dataelement-13626
    Id prsb03-dataelement-13626 (2020‑09‑08 19:49:07)
    Cardinality 0 … 1
    Description Record of Deprivation of Liberty Safeguards (DoLS) or equivalent, including the reason for this.
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Start date of authorisation 0 … 1
    prsb03-dataelement-13071
    Id prsb03-dataelement-13071 (2020‑05‑21 18:16:32)
    Cardinality 0 … 1
    Description The date the DOLs was authorised.
    Operationalization Data and time
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Planned or actual end date of authorisation 0 … 1
    prsb03-dataelement-13072
    Id prsb03-dataelement-13072 (2020‑05‑21 18:18:19)
    Cardinality 0 … 1
    Description The planned or actual end date of authorisation.
    Operationalization Date and time
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Mental health act or equivalent status 0 … 1
    prsb03-dataelement-10427
    Id prsb03-dataelement-10427 (2018‑10‑31)
    Cardinality 0 … 1
    Description Details of the persons mental health act record

    Properties

    Information Type Event.Record
    target Used by one transaction, 0 templates, inherited once
     
    draft Section start date 0 … 1
    prsb03-dataelement-10920
    Id prsb03-dataelement-10920 (2019‑04‑26 14:17:19)
    Cardinality 0 … 1
    Description The date the person was detained.
    Operationalization Date and time
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Section end date 0 … 1
    prsb03-dataelement-10921
    Id prsb03-dataelement-10921 (2019‑04‑26 14:19:05)
    Cardinality 0 … 1
    Description The date the person was no longer detained.
    Operationalization Date and time
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Mental health act or equivalent status 0 … 1
    prsb03-dataelement-13627
    Id prsb03-dataelement-13627 (2020‑09‑08 19:52:25)
    Cardinality 0 … 1
    Description 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.
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Coded value 0 … 1
    prsb03-dataelement-13628
    Id prsb03-dataelement-13628 (2020‑09‑08 19:57:06)
    Cardinality 0 … 1
    Description The coded value for mental health act
    Operationalization NHS data dictionary: - Mental health act legal status classification code
    Value Domain
    Property
    max length
    2
    Example Formally detained under Mental Health Act Section 2
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Free text 0 … 1
    prsb03-dataelement-13629
    Id prsb03-dataelement-13629 (2020‑09‑08 19:58:49)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
    Description Free text field to be used if no code is available
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Supporting information 0 … 1
    prsb03-dataelement-13755
    Id prsb03-dataelement-13755 (2020‑09‑29 11:48:32)
    Cardinality 0 … 1
    Description If person subject to Community Treatment Order or Conditional Discharge (or equivalent) record here.
    Operationalization NHS data dictionary : - Community treatment order
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Advance decision to refuse treatment (ADRT) 0 … 1
    prsb03-dataelement-10428
    Id prsb03-dataelement-10428 (2018‑10‑31)
    Cardinality 0 … 1
    Description Details of the person's ADRT status.

    Properties

    Information Type Event.Record

    target Used by one transaction, 0 templates, inherited once
     
    folder draft Advance decision to refuse treatment 0 … 1
    prsb03-dataelement-13502
    Id prsb03-dataelement-13502 (2020‑09‑02 17:36:30)
    Cardinality 0 … 1
    Description 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.
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Coded value 0 … 1
    prsb03-dataelement-13503
    Id prsb03-dataelement-13503 (2020‑09‑02 17:46:53)
    Cardinality 0 … 1
    Description The coded value for advance decision to refuse treatment.
    Operationalization SNOMED CT:- ^ 999002181000000105 |Advance decision to refuse treatment preference findings simple reference set (foundation metadata concept)|
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Free text 0 … 1
    prsb03-dataelement-13504
    Id prsb03-dataelement-13504 (2020‑09‑02 17:48:38)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
    Description Free text field to be used if no code is available
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Location of document 0 … 1
    prsb03-dataelement-22480
    Id prsb03-dataelement-22480 (2022‑04‑19 19:29:25)
    Cardinality 0 … 1
    Description Location of the advance decision to refuse treatment document 
    Operationalization


    Free text or URL
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Advance decision to refuse treatment (ADRT) 0 … 1
    prsb03-dataelement-12488
    Id prsb03-dataelement-12488 (2019‑10‑04 18:44:06)
    Cardinality 0 … 1
    Description 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.
    Operationalization
    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)
    Value Domain
    target Used by one transaction, 0 templates, inherited once
     
    draft Safeguarding issues 0 … 1
    prsb03-dataelement-10429
    Id prsb03-dataelement-10429 (2018‑10‑31)
    Cardinality 0 … 1
    Description Any legal matters relating to safeguarding of a vulnerable child or adult, e.g., child protection plan, protection of vulnerable adult.
    Operationalization Information obtained locally, Free Text.
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Parental responsibility 0 … 1
    prsb03-dataelement-10423
    Id prsb03-dataelement-10423 (2018‑10‑31)
    Cardinality 0 … 1
    Description For children this is a record of person(s) with parental responsibility
    Operationalization This 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.
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Consent for creation of end of life care plan 0 … 1
    prsb03-dataelement-10431
    Id prsb03-dataelement-10431 (2018‑10‑31)
    Cardinality 0 … 1
    Description 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.
    Operationalization End of life care plan use case only. This is a record of consent to create an end of life care plan.
    Value Domain
    target Used by one transaction, 0 templates, inherited once
     
    folder draft Safeguarding 0 … 1
    prsb03-dataelement-271
    Id prsb03-dataelement-271 (2018‑10‑31)
    Cardinality 0 … 1
    Description The safeguarding details of the person.
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Safeguarding concerns 0 … 1
    prsb03-dataelement-10821
    Id prsb03-dataelement-10821 (2019‑03‑21 12:14:49)
    Cardinality 0 … 1
    Description
    Details of safeguarding concerns.

    Properties

    Information Type Event.Record
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Safeguarding indicator 0 … 1
    prsb03-dataelement-13428
    Id prsb03-dataelement-13428 (2020‑08‑12 15:01:11) 0.1
    Cardinality 0 … 1
    Description Indicates whether or not the hospital considers that there are safeguarding issues associated with the patient.
    Operationalization Flag: No =N: Yes = Y
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Safeguarding concerns date 0 … 1
    prsb03-dataelement-10172
    Id prsb03-dataelement-10172 (2018‑10‑31)
    Cardinality 0 … 1
    Description The date the safeguarding concerns were identified.
    Operationalization Date and time
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Safeguarding concerns end date 0 … 1
    prsb03-dataelement-10766
    Id prsb03-dataelement-10766 (2019‑03‑18 17:51:29)
    Cardinality 0 … 1
    Description The date safeguarding concerns ended.
    Operationalization Date and time
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Safeguarding concerns 0 … 1
    prsb03-dataelement-10171
    Id prsb03-dataelement-10171 (2018‑10‑31)
    Cardinality 0 … 1
    Description Identified safeguarding concerns.

    Properties

    FHIR Composition.text
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Coded value 0 … 1
    prsb03-dataelement-13756
    Id prsb03-dataelement-13756 (2020‑09‑29 12:22:26)
    Cardinality 0 … 1
    Description The coded value for safeguarding concerns
    Operationalization SNOMED CT : - ^999002381000000108 | Safeguarding issues simple reference set (foundation metadata concept) |
    Value Domain
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Free text 0 … 1
    prsb03-dataelement-13757
    Id prsb03-dataelement-13757 (2020‑09‑29 12:23:18)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
    Description Free text field to be used if no code is available
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Comment 0 … 1
    prsb03-dataelement-10175
    Id prsb03-dataelement-10175 (2018‑10‑31)
    Cardinality 0 … 1
    Description Further details on safeguarding concerns.
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Looked after child 0 … 1
    prsb03-dataelement-10797
    Id prsb03-dataelement-10797 (2019‑03‑20 13:08:45)
    Cardinality 0 … 1
    Description
    Details of the looked after child.

    Properties

    Information Type Record
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Looked after child start date 0 … 1
    prsb03-dataelement-10746
    Id prsb03-dataelement-10746 (2019‑03‑07 11:47:56)
    Cardinality 0 … 1
    Description The date the child became a looked after child.
    Relationship
    Operationalization Date and time
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Looked after child end date 0 … 1
    prsb03-dataelement-10761
    Id prsb03-dataelement-10761 (2019‑03‑08 18:36:16)
    Cardinality 0 … 1
    Description The date the child ceased to be a looked after child.
    Operationalization Date and time
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Local authority 0 … 1
    prsb03-dataelement-10799
    Id prsb03-dataelement-10799 (2019‑03‑20 13:14:32)
    Cardinality 0 … 1
    Description The named local authority.
    Relationship
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Coded value 0 … 1
    prsb03-dataelement-13614
    Id prsb03-dataelement-13614 (2020‑09‑08 18:19:46)
    Cardinality 0 … 1
    Description The coded value for local authority
    Operationalization NHS data dictionary : - Organisation data service
    Value Domain
    Property
    min length max length
    3 5
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Free text 0 … 1
    prsb03-dataelement-13615
    Id prsb03-dataelement-13615 (2020‑09‑08 18:21:36)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
    Description Free text field to be used if no code is available
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Child protection plan 0 … 1
    prsb03-dataelement-10798
    Id prsb03-dataelement-10798 (2019‑03‑20 13:12:02)
    Cardinality 0 … 1
    Description Details of the child protection plan

    Properties

    Information Type Record
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Child protection plan start date 0 … 1
    prsb03-dataelement-10747
    Id prsb03-dataelement-10747 (2019‑03‑07 11:48:25)
    Cardinality 0 … 1
    Description The start date of the child protection plan
    Relationship
    Operationalization Date and time
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Child protection plan end date 0 … 1
    prsb03-dataelement-10762
    Id prsb03-dataelement-10762 (2019‑03‑08 18:36:48)
    Cardinality 0 … 1
    Description The end date of the child protection plan
    Operationalization Date and time
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Local authority 0 … 1
    prsb03-dataelement-10748
    Id prsb03-dataelement-10748 (2019‑03‑07 11:48:45)
    Cardinality 0 … 1
    Description The named local authority.
    Relationship
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Coded value 0 … 1
    prsb03-dataelement-13616
    Id prsb03-dataelement-13616 (2020‑09‑08 18:37:54)
    Cardinality 0 … 1
    Description The coded value for a local authority
    Operationalization NHS data dictionary : - organisation data service
    Value Domain
    Property
    min length max length
    3 5
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Free text 0 … 1
    prsb03-dataelement-13617
    Id prsb03-dataelement-13617 (2020‑09‑08 18:39:19)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
    Description Free text field to be used if no code is available
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Unborn child protection plan 0 … 1
    prsb03-dataelement-10923
    Id prsb03-dataelement-10923 (2019‑04‑26 17:54:37)
    Cardinality 0 … 1
    Description Details of the unborn child protection plan.

    Properties

    Information Type Record
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Unborn child protection plan start date 0 … 1
    prsb03-dataelement-10924
    Id prsb03-dataelement-10924 (2019‑04‑26 17:55:45)
    Cardinality 0 … 1
    Description Start date of the unborn child protection plan.
    Operationalization Date and time
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Unborn child protection plan end date 0 … 1
    prsb03-dataelement-10925
    Id prsb03-dataelement-10925 (2019‑04‑26 17:56:43)
    Cardinality 0 … 1
    Description End date of the unborn child protection plan.
    Operationalization Date and time
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Local authority 0 … 1
    prsb03-dataelement-10926
    Id prsb03-dataelement-10926 (2019‑04‑26 17:58:25)
    Cardinality 0 … 1
    Description The named local authority.
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Coded value 0 … 1
    prsb03-dataelement-13618
    Id prsb03-dataelement-13618 (2020‑09‑08 18:41:51)
    Cardinality 0 … 1
    Description The coded value for local authority
    Operationalization NHS data dictionary: - Organisation data service
    Value Domain
    Property
    min length max length
    3 5
    target Used by one transaction, 0 templates, inherited 0 times
     
    draft Free text 0 … 1
    prsb03-dataelement-13619
    Id prsb03-dataelement-13619 (2020‑09‑08 18:43:11)
    Cardinality 0 … 1
    Concept inherits from draft prsb03-dataelement-13220 (2020‑07‑08 12:57:49)
    Description Free text field to be used if no code is available
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited 0 times
     
    folder draft Risks 0 … *
    prsb03-dataelement-276
    Id prsb03-dataelement-276 (2018‑10‑31)
    Cardinality 0 … *
    Description Details of any risks related to the person.
    target Used by one transaction, 0 templates, inherited once
     
    folder draft Risks record entry 0 … 1
    prsb03-dataelement-14460
    Id prsb03-dataelement-14460 (2021‑08‑26 21:26:19)
    Cardinality 0 … 1
    Description This is a risks record entry. There may be 0 to many record entry/entries under a section. Each record entry is made up of a number of elements or data items.

    Properties

    FHIR Composition.text
    Information Type Event.Record
    Relationship
    target Used by one transaction, 0 templates, inherited once
     
    draft Start date of risk 0 … 1
    prsb03-dataelement-14461
    Id prsb03-dataelement-14461 (2021‑08‑26 21:27:13)
    Cardinality 0 … 1
    Description The start date of the risk.
    Relationship
    Operationalization Date and time
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited once
     
    draft End date of risk 0 … 1
    prsb03-dataelement-14462
    Id prsb03-dataelement-14462 (2021‑08‑26 21:27:13)
    Cardinality 0 … 1
    Description The date the risk ended.
    Relationship
    Operationalization Date and time
    Value Domain
    Property
    Timestamp precision
    at least day, month and year, hour and minute
    target Used by one transaction, 0 templates, inherited once
     
    folder draft Risk 0 … 1
    prsb03-dataelement-14463
    Id prsb03-dataelement-14463 (2021‑08‑26 21:27:13)
    Cardinality 0 … 1
    Description The risk to the person or others, this includes any risk the person might cause to themselves or to others. e.g. suicide, self harm. 
    Relationship
    Operationalization

    target Used by one transaction, 0 templates, inherited once
     
    draft Coded value 0 … 1
    prsb03-dataelement-21900
    Id prsb03-dataelement-21900 (2021‑12‑14 15:23:38)
    Cardinality 0 … 1
    Description The coded value for risk. 
    Relationship
    Operationalization

    SNOMED CT: - <281694009 |Finding of at risk (finding)|

     
    Value Domain
    target Used by one transaction, 0 templates, inherited once
     
    draft Free text 0 … 1
    prsb03-dataelement-21899
    Id prsb03-dataelement-21899 (2021‑12‑14 15:21:15)
    Cardinality 0 … 1
    Concept inherits from cancelled prsb03-dataelement-18782 (2021‑11‑23 11:27:26)
    Description Free text field to be used if no code is available.
    Relationship
    Operationalization Free text.
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited once
     
    draft Comment 0 … 1
    prsb03-dataelement-14485
    Id prsb03-dataelement-14485 (2021‑08‑26 21:33:03)
    Cardinality 0 … 1
    Description Additional details about the risk. 
    Operationalization Free text
    Value Domain
    Property
    max length
    150
    target Used by one transaction, 0 templates, inherited once