NHSE Metadata Catalogue

NHSE SD  > Digitising Social Care Data Standard Glossary @ 49219

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<span>Glossary created as part of the digitising social care programme.</span>


NHSE-SD Data Catalogue

Age Group

The adult social care survey asks people who are over 18 and who use adult social care about their experiences.

Adult Social Care Survey

Abuse is a violation of an individual's human and civil rights.
Abuse may consist of a single act or repeated acts and may affect one person or more. Abuse can take many forms the following are only examples. It may be physical, verbal, psychological, or discriminatory, it may be an act of neglect or an omission to act, or it may occur when a vulnerable person is persuaded to enter into a financial or sexual transaction to which he or she has not consented, or cannot consent. Abuse may take the form of honour based violence, modern slavery or exploitation.

Abuse

An indication of the type of accommodation that a client currently has. This should be based upon the client’s main or permanent residence.

Accommodation

Someone who puts a case on someone's else's behalf

Advocate

Age of person(s) calculated at a specific point in time.

A strong and often uncontrollable desire to drink or take drugs

Alcohol or drug dependency

Telecare services, as well as equipment and adaptations used to assist people.

Assistive equipment and technology

Asylum seekers are defined by the United Nations as people who move across borders in search of protection, but who may not fulfil the strict criteria laid down by the UNCHR 1951 Refugee Convention.
Asylum seeker describes someone who has applied for protection as a refugee and is awaiting the determination of his or her status.

Asylum Seeker

The information that people most want to share about themselves and that, when coded, can inform all health and social care records, for example, the PRSB Core Information Standard. See also: Reasonable Adjustments Flag.

About me

Admission details

Guidance on specific actions or activities that may be required or should be avoided

Actions and activities

Additional supporting plan, e.g. dieticians plan, wound management plan, discharge management plan and behaviour support plan.

Additional support plans

How the person was admitted to hospital e.g. elective, emergency, maternity, transfer etc.

Admission method

Admitted to

Provision of adult learning opportunities which can increase skills to support learners into work, enable attendees to gain qualifications, help attendees to meet new friends or simply find new hobbies or interests. Courses may be available full time, part time or online.

Adult education

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.

Advance decision to refuse treatment (ADRT)

Written requests and preferences made by a person with capacity conveying their wishes, beliefs and values for their future care should they lose capacity.

Advance statement

Alcohol intake

Alcohol misuse is when you drink in a way that's harmful, or when you're dependent on alcohol. To keep health risks from alcohol to a low level, both men and women are advised not to regularly drink more than 14 units a week. See https://www.nhs.uk/conditions/alcohol-misuse/

Alcohol misuse

Details of an alert, which should be determined locally. They might, for example, include the fact that the person has a dangerous dog. It is important that alerts are managed and removed when they are no longer relevant – e.g. “the dangerous dog” alert if the dog is no longer present. The alerts displayed to users viewing the core information may vary by use case and user’s role.

Alerts

Details about a person's allergies and adverse reactions

Allergies and adverse reactions

Guidance on specific interventions or actions that may be required or should be avoided in specific situations. A statement of anticipatory actions. Usually expressed as: in the event of X do Y.

Anticipatory actions

Medicines or equipment available that may be required in specific situations and their location. A statement regarding the availability or location of the anticipatory medicines/equipment for contingency planning.

Anticipatory medicines or equipment

Arts and cultural activities

An assessment of enhanced care observation that is needed and why

Assessed level of care

Informs the social services team that an assessment will be required, with expected discharge date if known.

Assessment notice

Assessment of personal well-being (PWB).P art of the wider Measuring National Well-being (MNW) Programme at the Office for National Statistics (ONS), which aims to provide accepted and trusted measures of the nation’s well-being.  See https://www.ons.gov.uk/peoplepopulationandcommunity/wellbeing/methodologies/personalwellbeingsurveyuserguide

Assessment using Personal Wellbeing Score

Assessment of wellbeing using the Short Warwick-Edinburgh Mental Well-being Scale (SWEMWBS). The SWEMWBS is a short version of the the Warwick–Edinburgh Mental Wellbeing Scale (WEMWBS), developed to enable the monitoring of mental wellbeing in the general population and the evaluation of projects, programmes and policies which aim to improve mental wellbeing. The SWEMWBS uses seven of the WEMWBS’s 14 statements about thoughts and feelings, which relate more to functioning than feelings and so offer a slightly different perspective on mental wellbeing. See https://www.corc.uk.net/outcome-experience-measures/short-warwick-edinburgh-mental-wellbeing-scale-swemws/

Assessment using Short Warwick-Edinburgh Mental Well-being Scale

Assessment of wellbeing using the Warwick-Edinburgh Mental Well-being Scale. The Warwick–Edinburgh Mental Wellbeing Scale (WEMWBS) was developed to enable the monitoring of mental wellbeing in the general population and the evaluation of projects, programmes and policies which aim to improve mental wellbeing. See https://www.corc.uk.net/outcome-experience-measures/warwick-edinburgh-mental-wellbeing-scale-wemws/

Assessment using Warwick-Edinburgh Mental Well-being Scale

Details about audio documents related to the person

Audio

Description of the level of awareness the person and or their carer/family has regarding their estimated prognosis in end of life care.

Awareness of prognosis

The type of the assessment e.g. social care needs assessment.

Assessment type

Indicates whether the plan was discussed and agreed with the person or legitimate representative and the decisions made.

Agreement for care and support plan

Information about the way in which information or facilities are accessible to all citizens and the steps taken to meet the required government standards so that people can do what they need to do in a similar amount of time and effort as someone that does not have a disability.

Dangerous occurrences or incidents that happen unexpectedly and unintentionally usually resulting in physical injuries

Accidents

The Adult Placement Scheme helps approved Adult Placement Carers (ordinary people from the local community) to share their home and time with someone in need. It is similar to fostering but for adults.

Adult placement

Alternative medicine and therapies

Autistic people may act in a different way to other people. Autistic people may:
-find it hard to communicate and interact with other people
-find it hard to understand how other people think or feel
-find things like bright lights or loud noises overwhelming, stressful or uncomfortable
-get anxious or upset about unfamiliar situations and social events
-take longer to understand information
-do or think the same things over and over

Autism

An Anatomical_Site is a structure of the human body.

Anatomical Site

Appointment e.g. diagnosis, investigation, treatment or assessment

Appointment

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.

Also worth knowing about me

When an assessment was completed after referral.

Assessment period

People registered as blind or sight impaired

Blind or severely sight impaired persons

Is the best interests requirement met, i.e. it is in the person's best interests to be deprived of their liberty in this care home or hospital for the purpose of giving the proposed care or treatment, it is necessary to prevent harm to that person, and it is proportionate to the risk and seriousness of that harm.

Best interests requirement

Bereavement is the experience of losing someone important to us.

Bereavement

A three digit number unique to each council with adult social services responsibilities

CASSR Code (Council with Adult Social Services Responsibility Code)

Support provided for carers with support needs such as:
-Carrying out any caring responsibilities the carer has for a child
-Providing care to other persons for whom the carer provides care
-Maintaining a habitable home environment in the carer’s home, whether or not this is also the home of the adult needing care
-Managing and maintaining nutrition
-Developing and maintaining family or other personal relationships
-Engaging in work, training, education or volunteering
-Making use of necessary facilities or services in the local community, including recreational facilities or services
-Engaging in recreational activities

Carer support

A combination of support and services that meet a person's assessed needs as part of a care plan

Care package

A unique number given by the Care Quality Commission to each location that they inspect. This includes care homes, domiciliary care agencies, hospitals, opticians etc.

CQC Location ID

CQC is the independent regulator of health and adult social care in England.

Care Quality Commission (CQC)

A unique number given by the Care Quality Commission to each provider that they inspect

CQC Provider ID

Cost of care

The process of assessing and reviewing a client's needs and arranging service delivery.

Care management

The definition of a carer is taken from the Carers and Disabled Children Act 2000 which utilises the following description: “Carers (aged 16 and over) who provide or intend to provide a substantial amount of care on a regular basis for another individual aged 18 or over”. Although the Act only refers to carers aged 16 and over, younger carers of adults should be included in this return. The Act excludes from the definition of a carer, paid care workers and volunteers from a voluntary organisation.
It is possible for a client to have more than one carer, and for a carer to additionally be a client in his or her own right.

Carer

The Carer Support Reason describes the needs of the carer. The carer’s support needs may change based on their personal circumstances and on the adult receiving care needs.

Carer support reason

Council with Adult Social Services Responsibility.

Council with Adult Social Services Responsibility (CASSR)

A client with a package of services provided by the CASSR but not within a personal budget, with no cash payments.

CASSR commissioned support only

A client in receipt of a personal budget where none of their personal budget is being taken as a direct payment.

CASSR managed personal budget

Customers of the CASSR who are ‘on the books’ for an assessment, a review or the receipt of services.

Client

Community is a very general term referring to the people living in a locality or to the locality itself.

Note: Welsh Communities are subdivisions of Unitary Authorities and their councils are the most local level of government in Wales. They are the equivalent of (civil) Parishes in England, but unlike English Parishes, Communities cover the whole of Wales.

Community

Decision about cardio-pulmonary resuscitation e.g. do not attempt cardiopulmonary resuscitation (DNAPR) who made the decision, the date of decision, date for review and location of documentation. Where the person or their family member/carer have not been informed of the clinical decision please state the reason why.

Cardio-pulmonary resuscitation (CPR) decision

Following a social care assessment the council will work with any adult who has social care needs to create a care and support plan which will detail how any eligible needs are to be met. The plan may also suggest ways of meeting needs for which the individual is not eligible to receive help from the council.

Care and support plan

Person looking after someone regularly because they're ill, elderly or disabled – including family members

An agent such as food, drug or substances that has caused or may cause an allergy, intolerance or adverse reaction in a person

Causative agent

Family support that can include help looking after your child, such as:
- day care for children under 5
- help with parenting – such as parenting classes
- courses or family support workers
- practical home help
- access to a Children's Centre
- support services provided by education or health authorities, or by voluntary organisations.

Childcare

Summary of a clinical encounter. Where possible, very brief. This may include interpretation of findings and results; differential diagnoses, opinion and specific action(s). Planned actions will be recorded under ‘plan’.

Clinical summary

Priority and reason for urgency of clinical referral if not routine.

Clinical urgency of referral

Description of how a person communicates normally including any communication aids they use, for example a hearing aid. Could include:
- preferred language of communication, if your first language is not English.
- how you would communicate when you are in pain or distress.
- communicate choices.
- how you give feedback or raise a concern.
- how you like to receive information

Communication

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. 
NOTE: This is a placeholder until the national guidance is published

Consent for information sharing

Record of whether consent has been obtained for the treatment. May include where record of consent is located or record of consent and a statement about the patient's consent for treatment.

Consent for treatment

The details of the person’s contact with a professional.

Contacts with professionals

A contingency plan is a plan that is agreed with a person or legitimate representative should a crisis occur. It enables all parties to understand the conditions and circumstances of the plan and the actions that should be taken if required.

Contingency plan

Coping strategies are defined as thoughts and behaviours that people use to manage the internal and external demands of situations that are appraised as stressful. This should also include a record of any tools used to carry out the coping strategy.

Copying strategies

Counselling services for individuals who have been identified as having particular needs to help sort through personal difficulties. These services may not be provided by the local authority but the authority may provide information on their availability.

Counselling

Current pregnancy

Contact details

Consultation method used e.g. face to face, telephone

Consultation method

A legal entity, or a sub-set of a legal entity, which may provide health and social care; it may operate on one or more sites.

This definition covers Local Authorities with social care responsibilities working in cooperation with an NHS Health Care Provider on nationally targeted and prioritised care as delivered within Care Spells. Lead responsibility for such care may be solely led by one Health Care Provider or jointly shared by two or more Health Care Providers each of which must share equal responsibility.

The following ORGANISATIONS may act as Health Care Providers:
-GP Practice
-NHS Trust
-NHS Foundation Trust
-Registered non-NHS Provider (e.g. Independent Provider, Independent Sector Healthcare Provider  etc)
-Unregistered non-NHS Provider
-Care Trust
-Local Authorities with social care responsibilities
-Other agencies

Care provider

Information in a form which identifies any individual, to whom the information relates or enables the identity of such an individual to be ascertained or any other information in respect of which the person who holds it owes a duty of confidence

Confidential information

Advice and information about contraception and access to emergency contraception services.

Contraception services

The priorities agreed between the person and their health/care team, where the person has capacity: To get better; please consider all treatment to prolong life. To achieve a balance between getting better and ensuring good quality of life; please consider selected treatments. Comfort; please consider all treatments aimed at symptom control.

Care priorities

Anyone who is caring for another person for a substantial amount of time has the right to have a carers assessment to identify their needs where either the person they are caring for has refused an assessment or is not receiving help from social care. The assessment is available to both adult carers and young carers.

Carer assessment

Details of the persons cognitive impairment.

Cognitive impairment

Details of the person's care act assessments

Care act assessment

Care and support needs identified as part of a care act assessment

Care and support needs

A reference to the persons funding source for care and any conditions or limitations associated.

Care funding source

A communal establishment is an establishment providing managed residential accommodation

Communal establishments

Cancer type

Information about the provision of care on a weekly basis.

Care provision

Care sequel

Casualty type

DoLS are a legal framework applying to individuals who lack the mental capacity to consent to the arrangements for their care. Where such care may amount to a "deprivation of liberty" the arrangements independently assessed to ensure they are in the best interests of the individual concerned (see https://digital.nhs.uk/data-and-information/publications/statistical/mental-capacity-act-2005-deprivation-of-liberty-safeguards-assessments/2020-21, https://www.gov.uk/government/publications/deprivation-of-liberty-safeguards-forms-and-guidance )

Deprivation of Liberty Safeguards (DoLS)

Under the Equality Act 2010, a disabled PERSON  is defined as "someone who has a physical or mental impairment that has a 'substantial' and 'long-term' negative effect on their ability to do normal daily activities.

Disability

Details of any responsibilities that a person has for other person(s) who rely on them for support.

Digitising Social Care Data Standard Glossary

Summary

Documentation

Origin