NHSE Metadata Catalogue

NHSE SD  > PRSB Core Information Standard Version 2.0 @ 24525

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PRSB.xml

core infor upload.xlsx

Medication item cluster-FINALIZED-11.docx

NHSE-SD Data Catalogue

Conformance:R
Cardinality:0 … 1
Description:The body site of the procedure
Value set:

Anatomical site

Conformance:R
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.
Value set:

Complications related to procedure

Description: About me
Conformance: R
Cardinality: 0 … 1
Type: Group

About me

Description: Additional support plans
Conformance: R
Cardinality: 0 … *
Type: Group

Additional support plans

Description:Admission details
Conformance:R
Cardinality:0 … 1
Type:Group

Admission details

Description:Details of alerts.
Cardinality:0 … 1
Type:Group

Alerts

Description: Allergies and adverse reactions
Conformance: R
Cardinality: 0 … 1
Type: Group

Allergies and adverse reactions

Description: Details of the person's assessments
Conformance: R
Cardinality: 0 … 1
Type: Group

Assessments

Description: This records the decisions reached during conversation between the individual and health and care professional about future plans and also records progress.
Conformance: R
Cardinality: 0 … 1
Type: Group

Care and support plan

Description: The details of the person’s contact with a professional.
Conformance: R
Cardinality: 0 … 1
Type: Group

Contacts with professionals

Description:These are the things to do and people to contact, should an individual’s health or other circumstances get worse for safety.
Conformance:R
Cardinality:0 … *
Type:Group

Contingency or safety plans

Description:Discharge details
Conformance:R
Cardinality:0 … 1
Type:Group

Discharge details

Description: Details about documents related to the person.
Conformance: R
Cardinality: 0 … 1
Type: Group

Documents (including correspondence, audio and images)

Description: Information relating to end of life care.
N.B. This is not an end of life care plan but contains information that would be found in an end of life care plan.
Conformance: R
Cardinality: 0 … 1
Type: Group

End of life care

Description: Details of equipment/asset (or modifications) that the Local Authority has provided to the patient.
Cardinality: 0 … 1
Type: Group

Equipment and adaptations

Description:Examination findings
Conformance:R
Cardinality:0 … 1
Type:Group

Examination findings

Description:Family history
Conformance:R
Cardinality:0 … 1
Type:Group

Family history

Description: Details of the person's formulation.
Conformance: R
Cardinality: 0 … 1
Type: Group

Formulation

Description:Details of future appointments.
Conformance:R
Cardinality:0 … 1
Type:Group

Future appointments

Description:Details of the person's GP practice.
Conformance:M
Cardinality:1 … 1
Type:Group

GP practice

Description:The individual requirements of the person.
Conformance:R
Cardinality:0 … 1
Type:Group

Individual requirements

Description: For each investigation, the result of the investigation. This can include a report which may have results for multiple tests.
Cardinality: 0 … 1
Type: Group
Parent Concept: Investigation results record entry

Investigation result

Description:Details of any investigations requested
Conformance:R
Cardinality:0 … 1
Type:Group

Investigations requested

Description:The legal information relating to the person.
Conformance:R
Cardinality:0 … 1
Type:Group

Legal information

Description: Medications and medical devices
Conformance: R
Cardinality: 0 … 1
Type: Group

Medications and medical devices

Description:Participation in research
Conformance:R
Cardinality:0 … 1
Type:Group

Participation in research

Description:The person's details and contact information.
Conformance:M
Cardinality:1 … 1
Type:Group

Person demographics

Description:The details of the individual's personal contacts.
Conformance:R
Cardinality:0 … 1
Type:Group

Personal contacts

Description: The details of planned investigations, procedures and treatment, and whether this plan has been agreed with the person or their legitimate representative.
Conformance: R
Cardinality: 0 … 1
Type: Group

Plan and requested actions

Description:Pregnancy status of the person.
Conformance:R
Cardinality:0 … 1
Type:Group

Pregnancy status

Description:The primary support reason for social care.
Conformance:R
Cardinality:0 … 1
Type:Group

Primary support reason

Description: A summary of the problems that require investigation or treatment.
Conformance: R
Cardinality: 0 … 1
Type: Group

Problem list

Description: The details of any procedures performed. Includes both psychological and medical therapies and procedures (e.g. cognitive behaviour therapy, hip replacement)
Conformance: R
Cardinality: 0 … 1
Type: Group

Procedures and therapies

Description:The details of the person’s professional contacts.
Conformance:R
Cardinality:0 … 1
Type:Group

Professional contacts

Description:The details of the referral.
Conformance:R
Cardinality:0 … 1
Type:Group

Referral details

Description:Details of any risks related to the person.
Conformance:R
Cardinality:0 … 1
Type:Group

Risks

Description: The investigation that is requested. The investigation may refer to an individual test or a group of related tests or broader investigation required (so the investigator can determine the appropriate tests)
Conformance: R
Cardinality: 1 … 1
Type: Group
Parent Concept: Investigations requested record entry

Investigation requested

Description:The safeguarding details of the person.
Conformance:R
Cardinality:0 … 1
Type:Group

Safeguarding

Description:The services and care provided for the person.
Conformance:R
Cardinality:0 … 1
Type:Group

Services and care

Description: The social setting in which the person lives, such as their household, occupational history, and lifestyle factors.
Conformance: R
Cardinality: 0 … 1
Type: Group

Social context

Description:Details of vaccinations.
Conformance:R
Cardinality:0 … 1
Type:Group

Vaccinations

Description:Investigation results
Conformance:R
Cardinality:0 … 1
Type:Group

Investigation results

Core

Conformance: R
Cardinality: 0 … 1
Description: For each investigation, the result of the investigation. This can include a report which may have results for multiple tests.
Value set:

Conformance:R
Cardinality:0 … 1
Description:Laterality of the procedure
Value set:

Laterality

Conformance:R
Cardinality:0 … 1
Description:The location the problem was identified.
Value set:

Location

Conformance:R
Cardinality:0 … 1
Description:The location where the occupational history was taken.
Value set:

Conformance: R
Cardinality: 0 … 1
Description: Details of the person completing the record.
Value set:

Person completing record

Conformance: R
Cardinality: 0 … 1
Description: The professional who prescribed the medication or medical device.
Value set:

Performing professional

Conformance: 
Cardinality: 0 … 1
Description: The form of the medication e.g. capsule, drops, tablet, lotion etc.
Value set:

Form

Conformance: 
Cardinality: 0 … 1
Description: The route by which the medication is administered e.g. oral, IM, IV
Value set:

Route

Conformance: 
Cardinality: 0 … 1
Description: The anatomical site at which the medication is to be administered.
Value set:

Site

Conformance: 
Cardinality: 0 … 1
Description: A structural representation of the elements carried by the dose syntax in 'parsable dose strength / timing' i.e. dose strength, dose timing, dose duration and maximum dose.
Value set:

Structured dose direction cluster

Conformance: R
Cardinality: 0 … 1
Description: Details of the overall course of medication.
Value set:

Course details cluster

Conformance: R
Cardinality: 0 … 1
Description: Records the changes made to medication.
Value set:

Medication change summary cluster

Conformance: R
Cardinality: 0 … 1
Description: Medication item cluster
Value set:

Medication item cluster

Cardinality:1 … 1
Description:The current and/or previous occupation(s) of the person.
Value set:

Occupational history

Conformance:R
Cardinality:0 … 1
Description:The professional who took the occupational history.
Value set:

Conformance:R
Cardinality:0 … 1
Description:The professional who performed the procedure.
Value set:

Conformance:R
Cardinality:0 … 1
Description:Details of the person completing the record.
Value set:

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.
Value set:

Procedure

Conformance: R
Cardinality: 0 … 1
Description: Details of where the allergy was identified. Linked to the date of the diagnosis by the professional.
Value set:

Cardinality: 0 … 1
Description: The substance, or a class of substances, that is considered to be responsible for the adverse reaction.
Value set:

Substance

Conformance: R
Cardinality: 0 … 1
Description: A description of the manifestation of the allergic or adverse reaction experienced by the person. For example, skin rash.
Value set:

Description of reaction

Cardinality: 0 … 1
Description: A description of the severity of the reaction.
Value set:

Severity

Cardinality: 0 … 1
Description: A description of the certainty that the stated causative agent caused the allergic or adverse reaction.
Value set:

Certainty

Cardinality: 0 … 1
Description: The route the person was exposed to the substance
Value set:

Route of exposure

Conformance: R
Cardinality: 0 … *
Description: Details of the reaction.
Value set:

Reaction details cluster

Conformance:R
Cardinality:0 … 1
Description:The service of the referrer.
Value set:

Service

Conformance:R
Cardinality:0 … 1
Description:The name of the organisation.
Value set:

Organisation

Conformance:R
Cardinality:0 … 1
Description:Details of where the referral is to be sent. If not an individual, this could be a service, e.g. GP surgery, department, specialty, subspecialty, educational institution, mental health etc.
Value set:

Referral to

Conformance:M
Cardinality:1 … 1
Description:The details of the referrer that is making the transfer. This could be the person, GP surgery, department, specialty, sub-specialty, educational institution, mental health team, care home etc.
Value set:

Referrer details

Conformance:R
Cardinality:0 … 1
Description:Details of any adverse reaction to any anesthetic agents including local anesthesia. Problematic intubation, transfusion reaction, etc.
Value set: