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draft Transaction General Health Information and Relevant History 2.16.840.1.113883.3.1937.777.28.4.435

Data Set PRSB Record structure and content 2.16.840.1.113883.3.1937.777.28.1.1

Name Id
draft General Health Information and Relevant History 2.16.840.1.113883.3.1937.777.28.4.435
Version / effective date Expiration 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.

Name Details [‑]
folder draft Relevant past medical, surgical and mental health history 0 … *
prsb03-dataelement-547
Id prsb03-dataelement-547 (2018‑10‑31)
Cardinality 0 … *
Description 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).
target Used by one transaction, 0 templates, inherited 0 times
 
draft Gynaecology 0 … *
prsb03-dataelement-10450
Id prsb03-dataelement-10450 (2018‑10‑31)
Cardinality 0 … *
Description 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.
Value Domain
target Used by one transaction, 0 templates, inherited 0 times
 
draft Past obstetric 0 … *
prsb03-dataelement-10451
Id prsb03-dataelement-10451 (2018‑10‑31)
Cardinality 0 … *
Description A record of the woman’s obstetric medical history relevant to the maternity episode. To include each previous pregnancy details and the outcome.
Value Domain
target Used by one transaction, 0 templates, inherited 0 times
 
draft Relevant past medical history 0 … *
prsb03-dataelement-10452
Id prsb03-dataelement-10452 (2018‑10‑31)
Cardinality 0 … *
Description The record of the person's significant medical, history. Including relevant previous diagnoses, health history problems and issues.
Value Domain
target Used by one transaction, 0 templates, inherited 0 times
 
draft Relevant past surgical history 0 … *
prsb03-dataelement-10453
Id prsb03-dataelement-10453 (2018‑10‑31)
Cardinality 0 … *
Description The record of the person’s significant surgical history. Including relevant issues, procedures, investigations, specific anaesthesia issues, etc.
Value Domain
target Used by one transaction, 0 templates, inherited 0 times
 
draft Relevant past mental health history 0 … *
prsb03-dataelement-10454
Id prsb03-dataelement-10454 (2018‑10‑31)
Cardinality 0 … *
Description A record of the person’s mental health history relevant to the episode
Value Domain
target Used by one transaction, 0 templates, inherited 0 times
 
draft Acute Hospital Episodes 0 … *
prsb03-dataelement-10455
Id prsb03-dataelement-10455 (2018‑10‑31)
Cardinality 0 … *
Description Reported details of any history of acute hospital episodes including ITU, HDU and A&E attendances the woman has had.
Value Domain
target Used by one transaction, 0 templates, inherited 0 times
 
draft Mental Health Admissions 0 … *
prsb03-dataelement-10456
Id prsb03-dataelement-10456 (2018‑10‑31)
Cardinality 0 … *
Description Reported details of any history of mental health admissions.
Value Domain
target Used by one transaction, 0 templates, inherited 0 times
 
draft Relevant past medical, surgical and mental health history 0 … *
prsb03-dataelement-12476
Id prsb03-dataelement-12476 (2019‑06‑27 12:35:48)
Cardinality 0 … *
Description 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.
Relationship
Operationalization A list of the person's relevant past medical, surgical and mental health history recorded in free text or coded form.
Value Domain
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft Problem list 0 … *
prsb03-dataelement-10927
Id prsb03-dataelement-10927 (2019‑04‑30 17:00:00)
Cardinality 0 … *
Description A summary of the problems that require investigation or treatment.
target Used by one transaction, 0 templates, inherited 3 times
 
folder draft Problem list record entry 0 … 1
prsb03-dataelement-10928
Id prsb03-dataelement-10928 (2019‑04‑30 17:01:01)
Cardinality 0 … 1
Description 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.

Properties

Information Type Event.Record
target Used by one transaction, 0 templates, inherited 3 times
 
folder draft Problem 0 … 1
prsb03-dataelement-10932
Id prsb03-dataelement-10932 (2019‑04‑30 17:08:40)
Cardinality 0 … 1
Description 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
Relationship
target Used by one transaction, 0 templates, inherited 6 times
 
draft Coded value 0 … 1
prsb03-dataelement-13244
Id prsb03-dataelement-13244 (2020‑07‑27 18:43:32)
Cardinality 0 … 1
Description The coded value for the problem list.
Operationalization SNOMED CT : - ^1127581000000103 |Health issues simple reference set|
Value Domain
target Used by one transaction, 0 templates, inherited 6 times
 
draft Free text 0 … 1
prsb03-dataelement-13245
Id prsb03-dataelement-13245 (2020‑07‑27 18:46:30)
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 25 times
 
draft Onset date 0 … 1
prsb03-dataelement-10933
Id prsb03-dataelement-10933 (2019‑04‑30 17:10:25)
Cardinality 0 … 1
Description A date or estimated date that the problem began
Relationship
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least month and year
target Used by one transaction, 0 templates, inherited 3 times
 
draft End Date 0 … 1
prsb03-dataelement-10934
Id prsb03-dataelement-10934 (2019‑04‑30 17:10:59)
Cardinality 0 … 1
Description The date or estimated date the problem was resolved.
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 3 times
 
folder draft Severity 0 … 1
prsb03-dataelement-18208
Id prsb03-dataelement-18208 (2021‑11‑16 12:43:07)
Cardinality 0 … 1
Description The severity of the problem. 
Relationship
target Used by one transaction, 0 templates, inherited 2 times
 
draft Coded value 0 … 1
prsb03-dataelement-18209
Id prsb03-dataelement-18209 (2021‑11‑16 12:44:20)
Cardinality 0 … 1
Description The coded value for severity. 
Relationship
Operationalization SNOMED CT.
Value Domain
target Used by one transaction, 0 templates, inherited 2 times
 
draft Free text 0 … 1
prsb03-dataelement-18210
Id prsb03-dataelement-18210 (2021‑11‑16 12:44:20)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13245 (2020‑07‑27 18:46:30)
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 8 times
 
folder draft Body site 0 … 1
prsb03-dataelement-18211
Id prsb03-dataelement-18211 (2021‑11‑16 12:51:30)
Cardinality 0 … 1
Description The body site relevant to the problem.
Relationship
target Used by one transaction, 0 templates, inherited 2 times
 
draft Coded value 0 … 1
prsb03-dataelement-18212
Id prsb03-dataelement-18212 (2021‑11‑16 12:52:44)
Cardinality 0 … 1
Description The coded value for body site. 
Relationship
Operationalization SNOMED CT.
Value Domain
target Used by one transaction, 0 templates, inherited 2 times
 
draft Free text 0 … 1
prsb03-dataelement-18213
Id prsb03-dataelement-18213 (2021‑11‑16 12:52:44)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-18210 (2021‑11‑16 12:44:20)
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 3 times
 
folder draft Laterality 0 … 1
prsb03-dataelement-18214
Id prsb03-dataelement-18214 (2021‑11‑16 13:10:51)
Cardinality 0 … 1
Description The laterality of the problem (left or right).
Relationship
target Used by one transaction, 0 templates, inherited 2 times
 
draft Coded value 0 … 1
prsb03-dataelement-18215
Id prsb03-dataelement-18215 (2021‑11‑16 13:11:44)
Cardinality 0 … 1
Description The coded value for laterality.
Relationship
Operationalization SNOMED CT.
Value Domain
target Used by one transaction, 0 templates, inherited 2 times
 
draft Free text 0 … 1
prsb03-dataelement-18216
Id prsb03-dataelement-18216 (2021‑11‑16 13:11:44)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-18210 (2021‑11‑16 12:44:20)
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 3 times
 
folder draft Stage of disease 0 … 1
prsb03-dataelement-18217
Id prsb03-dataelement-18217 (2021‑11‑16 13:26:16)
Cardinality 0 … 1
Description The stage of the disease where relevant.
Relationship
target Used by one transaction, 0 templates, inherited 2 times
 
draft Coded value 0 … 1
prsb03-dataelement-18218
Id prsb03-dataelement-18218 (2021‑11‑16 13:27:53)
Cardinality 0 … 1
Description The coded value for stage of disease.
Relationship
Operationalization SNOMED CT.
Value Domain
target Used by one transaction, 0 templates, inherited 2 times
 
draft Free text 0 … 1
prsb03-dataelement-18219
Id prsb03-dataelement-18219 (2021‑11‑16 13:27:53)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-18210 (2021‑11‑16 12:44:20)
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 2 times
 
folder draft Problem status 0 … 1
prsb03-dataelement-18220
Id prsb03-dataelement-18220 (2021‑11‑16 13:34:44)
Cardinality 0 … 1
Description The status of the problem. This can be either active or inactive.
Relationship
target Used by one transaction, 0 templates, inherited 2 times
 
draft Coded value 0 … 1
prsb03-dataelement-18221
Id prsb03-dataelement-18221 (2021‑11‑16 13:36:18)
Cardinality 0 … 1
Description The coded value for problem status.
Relationship
Operationalization SNOMED CT.
Value Domain
target Used by one transaction, 0 templates, inherited 2 times
 
draft Free text 0 … 1
prsb03-dataelement-18222
Id prsb03-dataelement-18222 (2021‑11‑16 13:36:18)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-18210 (2021‑11‑16 12:44:20)
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 3 times
 
folder draft Problem priority 0 … 1
prsb03-dataelement-18223
Id prsb03-dataelement-18223 (2021‑11‑16 13:43:14)
Cardinality 0 … 1
Description The problem priority level. This can be either significant or minor. 
Relationship
target Used by one transaction, 0 templates, inherited 2 times
 
draft Coded value 0 … 1
prsb03-dataelement-18224
Id prsb03-dataelement-18224 (2021‑11‑16 13:44:43)
Cardinality 0 … 1
Description The coded value for problem priority. 
Relationship
Operationalization SNOMED CT.
Value Domain
target Used by one transaction, 0 templates, inherited 2 times
 
draft Free text 0 … 1
prsb03-dataelement-18225
Id prsb03-dataelement-18225 (2021‑11‑16 13:44:43)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-18210 (2021‑11‑16 12:44:20)
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 2 times
 
folder draft Problem on discharge 0 … 1
prsb03-dataelement-14262
Id prsb03-dataelement-14262 (2021‑03‑10 15:51:43)
Cardinality 0 … 1
Description The main problem or diagnosis on discharge.

Problems may include diagnoses, symptoms, disabilities and social or behavioural issues, and comprise the ‘Problem list’
Relationship
target Used by one transaction, 0 templates, inherited 2 times
 
draft Coded value 0 … 1
prsb03-dataelement-14263
Id prsb03-dataelement-14263 (2021‑03‑10 15:53:09)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13244 (2020‑07‑27 18:43:32)
Description The coded value for the problem list.
Operationalization SNOMED CT : - ^1127581000000103 |Health issues simple reference set|
Value Domain
target Used by one transaction, 0 templates, inherited 2 times
 
draft Free text 0 … 1
prsb03-dataelement-14264
Id prsb03-dataelement-14264 (2021‑03‑10 15:53:09)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13245 (2020‑07‑27 18:46:30)
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 2 times
 
folder draft Procedures and therapies 0 … *
prsb03-dataelement-238
Id prsb03-dataelement-238 (2018‑10‑31)
Cardinality 0 … *
Description The details of any procedures performed. Includes both psychological and medical therapies and procedures (e.g. cognitive behaviour therapy, hip replacement)
target Used by one transaction, 0 templates, inherited once
 
folder draft Procedure record entry 0 … 1
prsb03-dataelement-10652
Id prsb03-dataelement-10652 (2018‑11‑13 12:02:22)
Cardinality 0 … 1
Description This is a procedure record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.

Properties

Information Type Event.Record
target Used by one transaction, 0 templates, inherited once
 
folder draft Procedure 0 … 1
prsb03-dataelement-10141
Id prsb03-dataelement-10141 (2018‑10‑31)
Cardinality 0 … 1
Description The therapeutic or diagnostic procedure performed. Includes both psychological and medical therapies and procedures (e.g. cognitive behaviour therapy, or follow-up interventions as a result of physical health checks). Complementary or alternative procedures and therapies should be recorded here.

Properties

FHIR Procedure.code
target Used by one transaction, 0 templates, inherited once
 
draft Coded value 0 … 1
prsb03-dataelement-13249
Id prsb03-dataelement-13249 (2020‑07‑27 19:35:09)
Cardinality 0 … 1
Description The procedure code.
Operationalization SNOMED CT : - << 71388002 |Procedure| OR << 129125009 |Procedure with explicit context|
Value Domain
target Used by one transaction, 0 templates, inherited once
 
draft Free text 0 … 1
prsb03-dataelement-13250
Id prsb03-dataelement-13250 (2020‑07‑27 19:40:38)
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 once
 
folder draft Anatomical site 0 … 1
prsb03-dataelement-10142
Id prsb03-dataelement-10142 (2018‑10‑31)
Cardinality 0 … 1
Description The body site of the procedure

Properties

FHIR Procedure.bodySite
target Used by one transaction, 0 templates, inherited 3 times
 
draft Coded value 0 … 1
prsb03-dataelement-13251
Id prsb03-dataelement-13251 (2020‑07‑27 19:46:07)
Cardinality 0 … 1
Description The coded value of the anatomical site.
Operationalization SNOMED CT :- < 123037004 |Body structure (body structure)|
Value Domain
target Used by one transaction, 0 templates, inherited 3 times
 
draft Free text 0 … 1
prsb03-dataelement-13252
Id prsb03-dataelement-13252 (2020‑07‑27 19:48:24)
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 3 times
 
folder draft Laterality 0 … 1
prsb03-dataelement-10143
Id prsb03-dataelement-10143 (2018‑10‑31)
Cardinality 0 … 1
Description Laterality of the procedure

Properties

FHIR ??Procedure.Code as an EXPRESSION Procedure.bodySite
target Used by one transaction, 0 templates, inherited once
 
draft Coded value 0 … 1
prsb03-dataelement-13253
Id prsb03-dataelement-13253 (2020‑07‑27 19:50:39)
Cardinality 0 … 1
Description The coded value for laterality.
Operationalization SNOMED CT:- < 182353008 |Side (qualifier value)|
Value Domain
target Used by one transaction, 0 templates, inherited once
 
draft Free text 0 … 1
prsb03-dataelement-13254
Id prsb03-dataelement-13254 (2020‑07‑27 19:52:35)
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 once
 
folder draft Complications related to procedure 0 … 1
prsb03-dataelement-10144
Id prsb03-dataelement-10144 (2018‑10‑31)
Cardinality 0 … 1
Description 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.

Properties

FHIR Procedure.complication Procedure.complicationDetail
Operationalization

target Used by one transaction, 0 templates, inherited once
 
draft Coded value 0 … 1
prsb03-dataelement-13255
Id prsb03-dataelement-13255 (2020‑07‑27 19:56:23)
Cardinality 0 … 1
Description The coded value for complications relating to procedure.
Operationalization SNOMED CT : - < 404684003 |Clinical finding (finding)|

Value Domain
target Used by one transaction, 0 templates, inherited once
 
draft Free text 0 … 1
prsb03-dataelement-13256
Id prsb03-dataelement-13256 (2020‑07‑27 19:58:17)
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 once
 
folder draft Social context 0 … *
prsb03-dataelement-136
Id prsb03-dataelement-136 (2018‑10‑31)
Cardinality 0 … *
Description The social setting in which the person lives, such as their household, occupational history, and lifestyle factors.
target Used by one transaction, 0 templates, inherited 0 times
 
draft Services and care 0 … *
prsb03-dataelement-12482
Id prsb03-dataelement-12482 (2019‑07‑01 12:40:21)
Cardinality 0 … *
Description The description of services and care providing support for person's health and social well-being.
Operationalization Free text. The record of the services and care as provided by the person or their representative.
Value Domain
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft Household composition 0 … 1
prsb03-dataelement-10036
Id prsb03-dataelement-10036 (2018‑10‑31)
Cardinality 0 … 1
Description Details of the person's household composition.

Properties

Information Type Event.Record
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft Household composition 0 … 1
prsb03-dataelement-13261
Id prsb03-dataelement-13261 (2020‑07‑28 12:00:25)
Cardinality 0 … 1
Description Description of the household composition e.g. lives alone, lives with family, lives with partner, shared accommodation etc.
target Used by one transaction, 0 templates, inherited 0 times
 
draft Coded value 0 … 1
prsb03-dataelement-13262
Id prsb03-dataelement-13262 (2020‑07‑28 12:15:50)
Cardinality 0 … 1
Description The coded value of household composition
Operationalization SNOMED CT: - 1027891000000106 | Household composition 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-13263
Id prsb03-dataelement-13263 (2020‑07‑28 12:20:28)
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 Occupational history 0 … *
prsb03-dataelement-10037
Id prsb03-dataelement-10037 (2018‑10‑31)
Cardinality 0 … *
Description The current and/or previous occupation(s) of the person.

Properties

FHIR Observation.category Observation.code Observation.valueCodeabelConcept Observation.subject
Information Type Event.Record
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft Occupational history 0 … 1
prsb03-dataelement-13264
Id prsb03-dataelement-13264 (2020‑07‑28 12:26:39)
Cardinality 0 … 1
Description The current and/or previous occupation(s) of the person.
target Used by one transaction, 0 templates, inherited 0 times
 
draft Coded value 0 … 1
prsb03-dataelement-13265
Id prsb03-dataelement-13265 (2020‑07‑28 12:27:26)
Cardinality 0 … 1
Description The coded value for occupational history
Operationalization SNOMED CT : - ^ 999001571000000109 | Occupation simple reference set (foundation metadata concept)
Value Domain
target Used by one transaction, 0 templates, inherited once
 
draft Free text 0 … 1
prsb03-dataelement-13266
Id prsb03-dataelement-13266 (2020‑07‑28 12:29:14)
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 Driving status 0 … 1
prsb03-dataelement-18226
Id prsb03-dataelement-18226 (2021‑11‑16 14:36:43)
Cardinality 0 … 1
Description The driving status of the person.

Properties

Information Type Event.Record
Relationship
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft Current driver 0 … 1
prsb03-dataelement-18231
Id prsb03-dataelement-18231 (2021‑11‑16 14:38:11)
Cardinality 0 … 1
Description Details of whether the person currently drives or not. 
Relationship
target Used by one transaction, 0 templates, inherited 0 times
 
draft Coded value 0 … 1
prsb03-dataelement-18232
Id prsb03-dataelement-18232 (2021‑11‑16 14:38:11)
Cardinality 0 … 1
Description The coded value for current driver.
Relationship
Operationalization SNOMED CT.
Value Domain
target Used by one transaction, 0 templates, inherited 0 times
 
draft Free text 0 … 1
prsb03-dataelement-18233
Id prsb03-dataelement-18233 (2021‑11‑16 14:38:11)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13350 (2020‑08‑06 17:16:53)
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 6 times
 
folder draft Educational history 0 … 1
prsb03-dataelement-10038
Id prsb03-dataelement-10038 (2018‑10‑31)
Cardinality 0 … 1
Description Details of the person's educational history.

Properties

Information Type Event.Record
target Used by one transaction, 0 templates, inherited 0 times
 
draft Educational history 0 … *
prsb03-dataelement-13840
Id prsb03-dataelement-13840 (2020‑12‑29 11:11:55)
Cardinality 0 … *
Description The current and/or previous relevant educational history of the person.
Operationalization Free text
Value Domain
Property
max length
150
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft Lifestyle choices 1 … 1
prsb03-dataelement-10039
Id prsb03-dataelement-10039 (2018‑10‑31)
Cardinality 1 … 1
Description 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

Properties

FHIR Text only
Information Type Event.Record
target Used by one transaction, 0 templates, inherited 0 times
 
draft Lifestyle choices 0 … *
prsb03-dataelement-13841
Id prsb03-dataelement-13841 (2020‑12‑29 11:26:28)
Cardinality 0 … *
Description 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.
Operationalization Free text
Value Domain
Property
max length
150
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft Nutrition 0 … 1
prsb03-dataelement-22674
Id prsb03-dataelement-22674 (2022‑05‑10 10:51:45)
Cardinality 0 … 1
Description
Details of the person's nutrition. 

Properties

Information Type Event.Record
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft Meal patterns 0 … *
prsb03-dataelement-22675
Id prsb03-dataelement-22675 (2022‑05‑10 14:00:02)
Cardinality 0 … *
Description Latest or current meal patterns. 
target Used by one transaction, 0 templates, inherited 0 times
 
draft Coded value 0 … 1
prsb03-dataelement-22677
Id prsb03-dataelement-22677 (2022‑05‑10 14:09:44)
Cardinality 0 … 1
Description The coded value for meal patterns. 
Operationalization SNOMED CT.
Value Domain
target Used by one transaction, 0 templates, inherited 0 times
 
draft Free text 0 … 1
prsb03-dataelement-22676
Id prsb03-dataelement-22676 (2022‑05‑10 14:02:25)
Cardinality 0 … 1
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
 
folder draft Nutritional findings 0 … *
prsb03-dataelement-23130
Id prsb03-dataelement-23130 (2022‑11‑01 12:36:15)
Cardinality 0 … *
Description
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.
Relationship
target Used by one transaction, 0 templates, inherited 0 times
 
draft Coded value 0 … 1
prsb03-dataelement-23131
Id prsb03-dataelement-23131 (2022‑11‑01 12:36:51)
Cardinality 0 … 1
Description
The coded value for nutritional findings.
Relationship
Operationalization SNOMED CT.
Value Domain
target Used by one transaction, 0 templates, inherited 0 times
 
draft Free text 0 … 1
prsb03-dataelement-23132
Id prsb03-dataelement-23132 (2022‑11‑01 12:36:51)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-22676 (2022‑05‑10 14:02:25)
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 0 times
 
folder draft Nutritional intake 0 … *
prsb03-dataelement-23126
Id prsb03-dataelement-23126 (2022‑11‑01 12:13:43)
Cardinality 0 … *
Description
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.
Relationship
target Used by one transaction, 0 templates, inherited 0 times
 
draft Coded value 0 … 1
prsb03-dataelement-23127
Id prsb03-dataelement-23127 (2022‑11‑01 12:14:42)
Cardinality 0 … 1
Description
The coded value for nutritional intake. 
Relationship
Operationalization SNOMED CT.

 

 

 
Value Domain
target Used by one transaction, 0 templates, inherited 0 times
 
draft Value 0 … 1
prsb03-dataelement-23128
Id prsb03-dataelement-23128 (2022‑11‑01 12:14:42)
Cardinality 0 … 1
Description
The value of nutritional intake. 
Relationship
Operationalization Numeric.
Value Domain
target Used by one transaction, 0 templates, inherited 0 times
 
draft Units of measure 0 … 1
prsb03-dataelement-23129
Id prsb03-dataelement-23129 (2022‑11‑01 12:14:42)
Cardinality 0 … 1
Description
The units of measure for nutritional intake.
Relationship
Operationalization UCUM code.



Value Domain
Property
max length
10
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft Carbohydrate intake 0 … *
prsb03-dataelement-22678
Id prsb03-dataelement-22678 (2022‑05‑11 16:14:20)
Cardinality 0 … *
Description
Quantifiable details of the person's carbohydrate intake e.g., measured or estimated intake in one meal or over a 24 hour period. 
Relationship
target Used by one transaction, 0 templates, inherited 0 times
 
draft Coded value 0 … 1
prsb03-dataelement-22682
Id prsb03-dataelement-22682 (2022‑05‑11 16:24:35)
Cardinality 0 … 1
Description The coded value for carbohydrate intake.
Relationship
Operationalization SNOMED CT.

 

 

 
Value Domain
target Used by one transaction, 0 templates, inherited 0 times
 
draft Value 0 … 1
prsb03-dataelement-22683
Id prsb03-dataelement-22683 (2022‑05‑11 16:24:35)
Cardinality 0 … 1
Description The value of carbohydrate intake.
Relationship
Operationalization Numeric.
Value Domain
target Used by one transaction, 0 templates, inherited 0 times
 
draft Units of measure 0 … 1
prsb03-dataelement-22684
Id prsb03-dataelement-22684 (2022‑05‑11 16:24:35)
Cardinality 0 … 1
Description
The units of measure for carbohydrate intake.
Relationship
Operationalization UCUM code.



Value Domain
Property
max length
10
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft Smoking status 0 … 1
prsb03-dataelement-10040
Id prsb03-dataelement-10040 (2018‑10‑31)
Cardinality 0 … 1
Description Details of the person's smoking status.

Properties

FHIR Observation.category Observation.code Observation.valueCodeabelConcept Observation.subject
Information Type Event.Record
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft Smoking status 0 … 1
prsb03-dataelement-13283
Id prsb03-dataelement-13283 (2020‑07‑30 17:12:22)
Cardinality 0 … 1
Description
Record of any smoking use by the person.
target Used by one transaction, 0 templates, inherited 0 times
 
draft Coded value 0 … 1
prsb03-dataelement-13284
Id prsb03-dataelement-13284 (2020‑07‑30 17:14:44)
Cardinality 0 … 1
Description The smoking status of the person.
Operationalization SNOMED CT:- ^999000891000000102 |Smoking 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-13285
Id prsb03-dataelement-13285 (2020‑07‑30 17:16:04)
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 Smoking record 0 … 1
prsb03-dataelement-13995
Id prsb03-dataelement-13995 (2021‑02‑11 18:40:13)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-12489 (2019‑10‑29 14:19:57)
Description Details of the person's smoking record
target Used by one transaction, 0 templates, inherited 0 times
 
draft Overall smoking status 0 … 1
prsb03-dataelement-13996
Id prsb03-dataelement-13996 (2021‑02‑11 18:40:44)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-12490 (2019‑10‑29 14:22:56)
Description

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

Defined by current smoking status and ever smoking status.

Operationalization

Coded text:

Current Smoker

Former Smoker

Never Smoked

^999000891000000102 |Smoking simple reference set (foundation metadata concept)|
Value Domain
target Used by one transaction, 0 templates, inherited 0 times
 
draft Date of quitting 0 … 1
prsb03-dataelement-13997
Id prsb03-dataelement-13997 (2021‑02‑11 18:40:44)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-12491 (2019‑10‑29 14:35:16)
Description Date when the individual stopped smoking (if a former smoker).
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least day, month and year
target Used by one transaction, 0 templates, inherited 0 times
 
draft Other tobacco products used 0 … 1
prsb03-dataelement-13998
Id prsb03-dataelement-13998 (2021‑02‑11 18:40:44)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-12492 (2019‑10‑29 14:40:14)
Description Details of other tobacco products used (e.g. shisha, pipe, cigar, heated tobacco products)
Operationalization

No other tobacco products used

Patient uses other tobacco products.

Plus free text details of products used.
Value Domain
target Used by one transaction, 0 templates, inherited 0 times
 
draft Information and advice given 0 … 1
prsb03-dataelement-13999
Id prsb03-dataelement-13999 (2021‑02‑11 18:40:44)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-12493 (2019‑10‑29 14:42:47)
Description Record of whether brief advice about available smoking cessation treatment/support was given at the time of consultation.

Properties

FHIR Free text only
Relationship
Operationalization

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
Value Domain
target Used by one transaction, 0 templates, inherited 0 times
 
draft Nicotine Replacement Therapy used 0 … 1
prsb03-dataelement-14000
Id prsb03-dataelement-14000 (2021‑02‑11 18:40:44)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-12495 (2019‑10‑29 16:11:19)
Description A record of whether nicotine replacement therapy (NRT) is currently used or prescribed in this appointment
Operationalization

NRT not currently used

NRT currently used

NRT prescribed at this appointment
Value Domain
target Used by one transaction, 0 templates, inherited 0 times
 
draft Varenicline or other pharmacotherapy used 0 … 1
prsb03-dataelement-14001
Id prsb03-dataelement-14001 (2021‑02‑11 18:40:44)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-12496 (2019‑10‑29 16:26:30)
Description Record of whether varenicline or other smoking cessation pharmacotherapy (other than nicotine replacement therapy) is currently used or prescribed in this appointment.
Operationalization

Varenicline/other pharmacotherapy not used

Varenicline/other pharmacotherapy currently used

Varenicline/other pharmacotherapy prescribed in this appointment
Value Domain
target Used by one transaction, 0 templates, inherited 0 times
 
draft e-cigarettes used 0 … 1
prsb03-dataelement-14002
Id prsb03-dataelement-14002 (2021‑02‑11 18:40:44)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-12497 (2019‑10‑29 16:35:51)
Description Record of current use of e-cigarettes
Operationalization

Coded - SNOMED CT:

722499006 |Electronic cigarette user (finding)|
Value Domain
target Used by one transaction, 0 templates, inherited 0 times
 
draft Therapy prescribed (see medication item entry information model) 0 … 1
prsb03-dataelement-14003
Id prsb03-dataelement-14003 (2021‑02‑11 18:40:44)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-12506 (2019‑10‑29 17:07:06)
Description Record of nicotine replacement therapy, varenicline or bupropion (or other smoking cessation pharmacotherapy) being prescribed at the time of the consultation
Operationalization To 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/
Value Domain
target Used by one transaction, 0 templates, inherited 0 times
 
draft Referral details 0 … 1
prsb03-dataelement-14004
Id prsb03-dataelement-14004 (2021‑02‑11 18:40:44)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-12508 (2019‑10‑29 17:08:47)
Description Record of whether referral to smoking cessation services was offered and/or made at the time of the consultation.
Operationalization

Referral to smoking cessation services

Referral not offered

Referral offered but declined

And free text with any additional information
Value Domain
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft Alcohol intake 0 … 1
prsb03-dataelement-10041
Id prsb03-dataelement-10041 (2018‑10‑31)
Cardinality 0 … 1
Description Details of the person's alcohol intake

Properties

FHIR Composition.text
Information Type Event.Record
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft Alcohol intake 0 … 1
prsb03-dataelement-13290
Id prsb03-dataelement-13290 (2020‑07‑31 17:02:46)
Cardinality 0 … 1
Description Latest or current alcohol consumption.
target Used by one transaction, 0 templates, inherited 0 times
 
draft Coded value 0 … 1
prsb03-dataelement-13291
Id prsb03-dataelement-13291 (2020‑07‑31 17:04:14)
Cardinality 0 … 1
Description The coded value of the person alcohol intake
Operationalization SNOMED 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)|
Value Domain
target Used by one transaction, 0 templates, inherited 0 times
 
draft Free text 0 … 1
prsb03-dataelement-13292
Id prsb03-dataelement-13292 (2020‑07‑31 17:11:04)
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 Drug/substance use 0 … *
prsb03-dataelement-10042
Id prsb03-dataelement-10042 (2018‑10‑31)
Cardinality 0 … *
Description Details of the person's drug and substance use.

Properties

Information Type Event.Record
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft Drug/substance use 0 … 1
prsb03-dataelement-13336
Id prsb03-dataelement-13336 (2020‑08‑06 16:36:01)
Cardinality 0 … 1
Description Latest or current drug/substance use.
target Used by one transaction, 0 templates, inherited 0 times
 
draft Coded value 0 … 1
prsb03-dataelement-13337
Id prsb03-dataelement-13337 (2020‑08‑06 16:44:34)
Cardinality 0 … 1
Description The coded value for drug and substance misuse.
Operationalization 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)|
Value Domain
target Used by one transaction, 0 templates, inherited 0 times
 
draft Free text 0 … 1
prsb03-dataelement-13338
Id prsb03-dataelement-13338 (2020‑08‑06 16:45:44)
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 Social circumstances 0 … *
prsb03-dataelement-10043
Id prsb03-dataelement-10043 (2018‑10‑31)
Cardinality 0 … *
Description Details of the persons social circumstances

Properties

Information Type Event.Record
target Used by one transaction, 0 templates, inherited 0 times
 
draft Social circumstances 0 … 1
prsb03-dataelement-13341
Id prsb03-dataelement-13341 (2020‑08‑06 16:51:45)
Cardinality 0 … 1
Description A person’s social background, network and personal circumstances, e.g. housing. This should include whether the person is a carer.
Operationalization Free text
Value Domain
Property
max length
150
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft Access 0 … *
prsb03-dataelement-10045
Id prsb03-dataelement-10045 (2018‑10‑31)
Cardinality 0 … *
Description Details of access for the person.

Properties

Information Type Event.Record
target Used by one transaction, 0 templates, inherited 0 times
 
draft Access 0 … 1
prsb03-dataelement-13342
Id prsb03-dataelement-13342 (2020‑08‑06 16:54:43)
Cardinality 0 … 1
Description Special access requirements e.g. key safe, coded lock, which door to use, stretcher access, etc.
Operationalization Free text
Value Domain
Property
max length
150
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft Dependants 0 … *
prsb03-dataelement-10046
Id prsb03-dataelement-10046 (2018‑10‑31)
Cardinality 0 … *
Description Details of any responsibility the person has for dependants.

Properties

Information Type Event.Record
target Used by one transaction, 0 templates, inherited 0 times
 
draft Dependants 0 … 1
prsb03-dataelement-13345
Id prsb03-dataelement-13345 (2020‑08‑06 17:05:40)
Cardinality 0 … 1
Description Provide details of any responsibility the person has for dependants. In the case of children provide date of birth of the child.
Operationalization Free text
Value Domain
Property
max length
150
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft Accommodation status 0 … *
prsb03-dataelement-10047
Id prsb03-dataelement-10047 (2018‑10‑31)
Cardinality 0 … *
Description Details of the type of accommodation where the person lives.

Properties

Information Type Event.Record
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft Accommodation status 0 … 1
prsb03-dataelement-13348
Id prsb03-dataelement-13348 (2020‑08‑06 17:12:04)
Cardinality 0 … 1
Description An indication of the type of accommodation where the person lives.

This should be based on the main or permanent residence.
target Used by one transaction, 0 templates, inherited 0 times
 
draft Coded value 0 … 1
prsb03-dataelement-13349
Id prsb03-dataelement-13349 (2020‑08‑06 17:13:26)
Cardinality 0 … 1
Description The coded value for accommodation status
Operationalization NHS data dictionary :- Accommodation status
Value Domain
Property
max length
4
target Used by one transaction, 0 templates, inherited 0 times
 
draft Free text 0 … 1
prsb03-dataelement-13350
Id prsb03-dataelement-13350 (2020‑08‑06 17:16:53)
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 once
 
folder draft Household environment 0 … *
prsb03-dataelement-10051
Id prsb03-dataelement-10051 (2018‑10‑31)
Cardinality 0 … *
Description Details of the person's household environment.

Properties

Information Type Event.Record
target Used by one transaction, 0 templates, inherited 0 times
 
draft Household environment 0 … 1
prsb03-dataelement-13842
Id prsb03-dataelement-13842 (2020‑12‑29 12:11:12)
Cardinality 0 … 1
Description Factors in the household which impact the person's health and wellbeing, to include smoking in the home, alcohol/substance use etc.
Operationalization Free text
Value Domain
Property
min length max length
3 5
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft Investigation results 0 … *
prsb03-dataelement-257
Id prsb03-dataelement-257 (2018‑10‑31)
Cardinality 0 … *
Description Investigation results
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft Investigation results record entry 0 … 1
prsb03-dataelement-10654
Id prsb03-dataelement-10654 (2018‑11‑13 12:10:48)
Cardinality 0 … 1
Description This is a investigation result record entry. There may be 0 to many record entries under a section. Each record entry is made up of a number of elements or data items.

Properties

Information Type Event.Record
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft Investigation 0 … 1
prsb03-dataelement-10160
Id prsb03-dataelement-10160 (2018‑10‑31)
Cardinality 0 … 1
Description The investigation performed.
target Used by one transaction, 0 templates, inherited 0 times
 
draft Coded value 0 … 1
prsb03-dataelement-13525
Id prsb03-dataelement-13525 (2020‑09‑04 14:11:36)
Cardinality 0 … 1
Description The coded value for investigation
Operationalization SNOMED CT: - <71388002 |Procedure (procedure)|

Value Domain
target Used by one transaction, 0 templates, inherited 0 times
 
draft Free text 0 … 1
prsb03-dataelement-13526
Id prsb03-dataelement-13526 (2020‑09‑04 14:22:43)
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 Investigation result 0 … 1
prsb03-dataelement-10161
Id prsb03-dataelement-10161 (2018‑10‑31)
Cardinality 0 … 1
Description For each investigation, the result of the investigation. This can include a report which may have results for multiple tests.
target Used by one transaction, 0 templates, inherited 0 times
 
draft Coded value 0 … 1
prsb03-dataelement-13527
Id prsb03-dataelement-13527 (2020‑09‑04 14:25:41)
Cardinality 0 … 1
Description The coded value for investigation results
Operationalization SNOMED CT:- <404684003 |Clinical finding (finding)| OR <243796009 |Situation with explicit context (situation)|

Value Domain
target Used by one transaction, 0 templates, inherited 0 times
 
draft Free text 0 … 1
prsb03-dataelement-13528
Id prsb03-dataelement-13528 (2020‑09‑04 14:29:50)
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
 
draft Investigation Method 0 … 1
prsb03-dataelement-14094
Id prsb03-dataelement-14094 (2021‑02‑18 13:46:34)
Cardinality 0 … 1
Description Method used in carrying out investigation
Operationalization Coded entry - Point of care test, Laboratory test
Value Domain
target Used by one transaction, 0 templates, inherited once
 
folder draft Structured investigation result 0 … 1
prsb03-dataelement-12415
Id prsb03-dataelement-12415 (2019‑06‑07 16:21:34)
Cardinality 0 … 1
Description A structured set of information for each investigation result.
target Used by one transaction, 0 templates, inherited 0 times
 
draft Value 0 … 1
prsb03-dataelement-12416
Id prsb03-dataelement-12416 (2019‑06‑07 16:22:08)
Cardinality 0 … 1
Description The value of the investigation result.
Operationalization Numeric
Value Domain
Property
max length
10
target Used by one transaction, 0 templates, inherited 0 times
 
draft Units of measure 0 … 1
prsb03-dataelement-12417
Id prsb03-dataelement-12417 (2019‑06‑07 16:23:50)
Cardinality 0 … 1
Description The units of the investigation result.
Operationalization UCUM code
Value Domain
Property
max length
10
target Used by one transaction, 0 templates, inherited 0 times
 
draft Reference ranges 0 … 1
prsb03-dataelement-12418
Id prsb03-dataelement-12418 (2019‑06‑07 16:24:48)
Cardinality 0 … 1
Description The reference range for the investigation result.
Operationalization Free text
Value Domain
target Used by one transaction, 0 templates, inherited 0 times
 
draft Abnormal indicator 0 … 1
prsb03-dataelement-12419
Id prsb03-dataelement-12419 (2019‑06‑07 16:26:00)
Cardinality 0 … 1
Description Indicator if the investigation is abnormal.
Operationalization Abnormal or Normal
Value Domain
target Used by one transaction, 0 templates, inherited once
 
folder draft Allergies and adverse reactions 0 … *
prsb03-dataelement-282
Id prsb03-dataelement-282 (2018‑10‑31)
Cardinality 0 … *
Description Allergies and adverse reactions
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft Allergies and adverse reactions record entry 0 … 1
prsb03-dataelement-10657
Id prsb03-dataelement-10657 (2018‑11‑13 12:23:03)
Cardinality 0 … 1
Description 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.

Properties

Information Type Event.Record
target Used by one transaction, 0 templates, inherited 0 times
 
draft Type of reaction 0 … 1
prsb03-dataelement-10186
Id prsb03-dataelement-10186 (2018‑10‑31)
Cardinality 0 … 1
Description The type of reaction experienced by the person (allergic, adverse, intolerance)

Properties

FHIR AllergyIntolerance.type
Rationale AllergyIntolerance.type
Operationalization FHIR value set :- Allergy, Intolerance
Value Domain
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft Causative agent 0 … 1
prsb03-dataelement-10182
Id prsb03-dataelement-10182 (2018‑10‑31)
Cardinality 0 … 1
Description The agent such as food, drug or substances that has caused or may cause an allergy, intolerance or adverse reaction in this person Or “No known drug allergies or adverse reactions” Or “Information not available”

Properties

FHIR AllergyIntolerance.code
target Used by one transaction, 0 templates, inherited 0 times
 
draft Coded value 0 … 1
prsb03-dataelement-13441
Id prsb03-dataelement-13441 (2020‑08‑19 14:12:48)
Cardinality 0 … 1
Description The coded value for causative agent
Rationale Allergyintolerance.code
Operationalization
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)

Value Domain
target Used by one transaction, 0 templates, inherited 0 times
 
draft Free text 0 … 1
prsb03-dataelement-13442
Id prsb03-dataelement-13442 (2020‑08‑19 15:33:40)
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 Reaction details cluster 0 … 1
prsb03-dataelement-10658
Id prsb03-dataelement-10658 (2018‑11‑13 12:29:25)
Cardinality 0 … 1
Description Details of the reaction.

Properties

Information Type Event.Record
target Used by one transaction, 0 templates, inherited 0 times
 
draft Date 0 … 1
prsb03-dataelement-10190
Id prsb03-dataelement-10190 (2018‑10‑31)
Cardinality 0 … 1
Description The date that the reaction was identified.

Properties

FHIR dateAsserted
Rationale Allergyintolerance.asserteddate
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 Substance 0 … 1
prsb03-dataelement-11665
Id prsb03-dataelement-11665 (2019‑05‑30 20:17:32)
Cardinality 0 … 1
Description The substance, or a class of substances, that is considered to be responsible for the adverse reaction.
target Used by one transaction, 0 templates, inherited 0 times
 
draft Coded value 0 … 1
prsb03-dataelement-13554
Id prsb03-dataelement-13554 (2020‑09‑04 16:44:48)
Cardinality 0 … 1
Description The coded value for substance
Rationale AllergyIntolerance. reaction.substance
Operationalization SNOMED CT : - <105590001 | Substance (substance) | or <373873005 | Pharmaceutical / biologic product (product) |

Value Domain
target Used by one transaction, 0 templates, inherited 0 times
 
draft Free text 0 … 1
prsb03-dataelement-13555
Id prsb03-dataelement-13555 (2020‑09‑04 16:45:54)
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 Description of reaction 0 … 1
prsb03-dataelement-10183
Id prsb03-dataelement-10183 (2018‑10‑31)
Cardinality 0 … 1
Description A description of the manifestation of the allergic or adverse reaction experienced by the person. For example, skin rash.

Properties

FHIR AllergyIntolerance.reaction.manifestation AllergyIntolerance.reaction.description
target Used by one transaction, 0 templates, inherited 0 times
 
draft Coded value 0 … 1
prsb03-dataelement-13556
Id prsb03-dataelement-13556 (2020‑09‑04 16:48:37)
Cardinality 0 … 1
Description The coded value for description of reaction.
Rationale AllergyIntolerance.reaction.manifestation
Operationalization SNOMED CT: - ^1127581000000103 |Health issues simple reference set|
Value Domain
target Used by one transaction, 0 templates, inherited 0 times
 
draft Free text 0 … 1
prsb03-dataelement-13557
Id prsb03-dataelement-13557 (2020‑09‑04 16:51:03)
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 Onset date 0 … 1
prsb03-dataelement-13844
Id prsb03-dataelement-13844 (2020‑12‑29 22:44:39)
Cardinality 0 … 1
Description Date and time when manifestations showed e.g could be at home a few days earlier than the contact
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least year
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft Severity 0 … 1
prsb03-dataelement-10184
Id prsb03-dataelement-10184 (2018‑10‑31)
Cardinality 0 … 1
Description A description of the severity of the reaction.

Properties

FHIR AllergyIntolerance.reaction.severity
target Used by one transaction, 0 templates, inherited 0 times
 
draft Coded value 0 … 1
prsb03-dataelement-13558
Id prsb03-dataelement-13558 (2020‑09‑04 17:43:42)
Cardinality 0 … 1
Description The coded value for severity
Rationale AllergyIntolerance.reaction.severity
Operationalization FHIR value set : - Severity
Value Domain
target Used by one transaction, 0 templates, inherited 0 times
 
draft Free text 0 … 1
prsb03-dataelement-13559
Id prsb03-dataelement-13559 (2020‑09‑04 17:48:53)
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 Certainty 0 … 1
prsb03-dataelement-10185
Id prsb03-dataelement-10185 (2018‑10‑31)
Cardinality 0 … 1
Description A description of the certainty that the stated causative agent caused the allergic or adverse reaction.

Properties

FHIR AllergyIntolerance.verificationStatus
target Used by one transaction, 0 templates, inherited 0 times
 
draft Coded value 0 … 1
prsb03-dataelement-13560
Id prsb03-dataelement-13560 (2020‑09‑04 17:52:26)
Cardinality 0 … 1
Description The coded value for certainty.
Rationale AllergyIntolerance.verificationStatus
Operationalization FHIR value set : - Certainty
Value Domain
target Used by one transaction, 0 templates, inherited once
 
draft Free text 0 … 1
prsb03-dataelement-13561
Id prsb03-dataelement-13561 (2020‑09‑04 17:55:21)
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 once
 
folder draft Route of exposure 0 … 1
prsb03-dataelement-13856
Id prsb03-dataelement-13856 (2021‑01‑18 18:45:19)
Cardinality 0 … 1
Description The route the person was exposed to the substance
target Used by one transaction, 0 templates, inherited 0 times
 
draft Coded value 0 … 1
prsb03-dataelement-13857
Id prsb03-dataelement-13857 (2021‑01‑18 18:50:12)
Cardinality 0 … 1
Description The coded value for route of exposure
Rationale AllergyIntolerance.exposureroute
Operationalization SNOMED CT: - ^999000051000001100 |ePrescribing route of administration simple reference set|
Value Domain
target Used by one transaction, 0 templates, inherited once
 
draft Free text 0 … 1
prsb03-dataelement-13858
Id prsb03-dataelement-13858 (2021‑01‑18 18:55:02)
Cardinality 0 … 1
Description Free text field to be used if no coded text available
Relationship
Operationalization Free text 
Value Domain
Property
max length
150
target Used by one transaction, 0 templates, inherited once
 
draft Evidence 0 … 1
prsb03-dataelement-10187
Id prsb03-dataelement-10187 (2018‑10‑31)
Cardinality 0 … 1
Description Results of investigations that confirmed the certainty of the diagnosis. Examples might include results of skin prick allergy tests

Properties

FHIR AllergyIntolerance.extension.evidence
Rationale AllergyIntolerance.extension.evidence
Operationalization Free text
Value Domain
Property
max length
150
target Used by one transaction, 0 templates, inherited 0 times
 
draft Date first experienced 0 … 1
prsb03-dataelement-10188
Id prsb03-dataelement-10188 (2018‑10‑31)
Cardinality 0 … 1
Description
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)

Properties

FHIR AllergyIntolerance.onset[x]
Rationale AllergyIntolerance.onset
Operationalization Date and time
Value Domain
Property
Timestamp precision
at least year
target Used by one transaction, 0 templates, inherited 0 times
 
draft Allergy end date 0 … 1
prsb03-dataelement-14253
Id prsb03-dataelement-14253 (2021‑03‑04 13:29:34)
Cardinality 0 … 1
Description The date the allergy was diagnosed as ended
Operationalization Date and time 
Value Domain
Property
Timestamp precision
at least year
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft Medications and medical devices 0 … *
prsb03-dataelement-636
Id prsb03-dataelement-636 (2018‑10‑31)
Cardinality 0 … *
Description Medications and medical devices
target Used by one transaction, 0 templates, inherited once
 
folder draft Medication administration record entry 0 … 1
prsb03-dataelement-12483
Id prsb03-dataelement-12483 (2019‑07‑03 12:24:36)
Cardinality 0 … 1
Description Each entry holds details of medications administered

Properties

Information Type Event.Record
target Used by one transaction, 0 templates, inherited once
 
folder draft Medication name 0 … 1
prsb03-dataelement-12484
Id prsb03-dataelement-12484 (2019‑07‑03 12:27:06)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-10536 (2018‑10‑31)
Description May be generic name or brand name.

Properties

FHIR MedicationStatement.medication[x].medicationCodableConcept MedicationStatement.medication[x].medicationReference (see Medication) (Systems should send as much details as they can. dm+d code can be sent as a simple code/description pair using CodeableConcept, or as a detailed medication record)
target Used by one transaction, 0 templates, inherited once
 
draft Coded value 0 … 1
prsb03-dataelement-13663
Id prsb03-dataelement-13663 (2020‑09‑08 21:49:56)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13622 (2020‑09‑08 19:15:21)
Description The coded value for medication name
Rationale MedicationStatement.medication[x].medicationCodableConcept

Operationalization dm+d:- any code from the VTM, VMP, AMP, VMPP and AMPP concept classes
Value Domain
target Used by one transaction, 0 templates, inherited 0 times
 
draft Free text 0 … 1
prsb03-dataelement-13664
Id prsb03-dataelement-13664 (2020‑09‑08 21:49:56)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13623 (2020‑09‑08 19:17:39)
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 Method 0 … 1
prsb03-dataelement-18205
Id prsb03-dataelement-18205 (2021‑11‑15 12:24:22)
Cardinality 0 … 1
Description The technique or method by which the medication is to be administered.

Properties

FHIR MedicationStatement.dosage.method
Relationship
target Used by one transaction, 0 templates, inherited 0 times
 
draft Coded value 0 … 1
prsb03-dataelement-18206
Id prsb03-dataelement-18206 (2021‑11‑15 12:25:27)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13845 (2020‑12‑29 23:05:59)
Description The coded value for method
Rationale MedicationStatement.dosage.method
Operationalization SNOMED CT : - ^999000041000001103 | ePrescribing method 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-18207
Id prsb03-dataelement-18207 (2021‑11‑15 12:25:27)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13846 (2020‑12‑29 23:07:37)
Description Free text field to be used if no coded text available
Value Domain
Property
max length
150
target Used by one transaction, 0 templates, inherited 0 times
 
folder draft Route 0 … 1
prsb03-dataelement-12485
Id prsb03-dataelement-12485 (2019‑07‑03 12:28:40)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-10538 (2018‑10‑31)
Description The route by which the medication is administered e.g. oral, IM, IV

Properties

FHIR MedicationStatement.dosage.route
target Used by one transaction, 0 templates, inherited once
 
draft Coded value 0 … 1
prsb03-dataelement-13661
Id prsb03-dataelement-13661 (2020‑09‑08 21:47:04)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13655 (2020‑09‑08 20:30:38)
Description The coded value for route
Rationale MedicationStatement.dosage.route

Operationalization SNOMED CT: - ^999000051000001100 |ePrescribing route of administration 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-13662
Id prsb03-dataelement-13662 (2020‑09‑08 21:47:04)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13656 (2020‑09‑08 20:31:40)
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 Device type 0 … 1
prsb03-dataelement-21033
Id prsb03-dataelement-21033 (2021‑12‑13 22:44:45)
Cardinality 0 … 1
Description The device type. 
Relationship
target Used by one transaction, 0 templates, inherited 0 times
 
draft Coded value 0 … 1
prsb03-dataelement-21034
Id prsb03-dataelement-21034 (2021‑12‑13 22:46:18)
Cardinality 0 … 1
Description The coded value for device type.
Relationship
Operationalization SNOMED CT.
Value Domain
target Used by one transaction, 0 templates, inherited 0 times
 
draft Free text 0 … 1
prsb03-dataelement-21035
Id prsb03-dataelement-21035 (2021‑12‑13 22:46:18)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-13245 (2020‑07‑27 18:46:30)
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 3 times
 
folder draft Dose context 0 … 1
prsb03-dataelement-23072
Id prsb03-dataelement-23072 (2022‑10‑26 11:48:36)
Cardinality 0 … 1
Description
Supporting information about the dose administered e.g., carbohydrate coverage or high blood sugar correction insulin dose.
target Used by one transaction, 0 templates, inherited 0 times
 
draft Coded value 0 … 1
prsb03-dataelement-18391
Id prsb03-dataelement-18391 (2021‑11‑22 22:10:38)
Cardinality 0 … 1
Description
The coded value for dose context. 
Relationship
Rationale

Operationalization SNOMED CT.
Value Domain
target Used by one transaction, 0 templates, inherited 0 times
 
draft Free text 0 … 1
prsb03-dataelement-23073
Id prsb03-dataelement-23073 (2022‑10‑26 12:33:51)
Cardinality 0 … 1
Concept inherits from draft prsb03-dataelement-22520 (2022‑05‑09 14:13:37)
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
 
folder draft Dose administered 0 … 1
prsb03-dataelement-18390
Id prsb03-dataelement-18390 (2021‑11‑22 22:09:37)
Cardinality 0 … 1
Description Details of dose administered.
Relationship
target Used by one transaction, 0 templates, inherited 0 times
 
draft Value 0 … 1
prsb03-dataelement-18392
Id prsb03-dataelement-18392 (2021‑11‑22 22:10:38)
Cardinality 0 … 1
Description The value for dose administered.
Relationship
Operationalization Numerical value.
Value Domain
target Used by one transaction, 0 templates, inherited 0 times
 
draft Units of measure 0 … 1
prsb03-dataelement-18393
Id prsb03-dataelement-18393 (2021‑11‑22 22:10:38)
Cardinality 0 … 1
Description The units of measure for dose administered. 
Relationship
Operationalization UCUM code.
Value Domain
Property
max length
10
target Used by one transaction, 0 templates, inherited once
 
draft Administration date and time 0 … 1
prsb03-dataelement-20999
Id prsb03-dataelement-20999 (2021‑12‑13 12:51:07)
Cardinality 0 … 1
Description The date and time when the medication was administered.
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 Start date/time 0 … 1
prsb03-dataelement-21014
Id prsb03-dataelement-21014 (2021‑12‑13 17:05:22)
Cardinality 0 … 1
Description The date and time that the infusion started. 
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/time 0 … 1
prsb03-dataelement-21015
Id prsb03-dataelement-21015 (2021‑12‑13 17:10:19)
Cardinality 0 … 1
Description The date and time that the infusion 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