NHSE Metadata Catalogue

NHSE SD  > Adult Social Care Record (MODS) @ 86081

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MODS V1.0.1 Data Dictionary.xlsx

Conceptual Model

Introduction to the MODS

FHIR Profiles

<span>The Adult Social Care Record (MODS) exists to ensure a consistent baseline collection of direct care data by CQC registered adult social care providers. To enable interoperability and ensure data collected supports the delivery of quality care.</span>
<span>The team are looking for constructive feedback to improve the MODS from the health and social care community and this can be provided through the Digital Social Care Data Standards Service Desk (https://metadata.atlassian.net/servicedesk/customer/portal/16/group/34/create/208)</span>


The Digital Social Care Records Capabilities and Standards Roadmap

NHSE-SD Data Catalogue

Details about documents related to the person.

Document

Details of a scheduled re-assessment of a person’s needs and/or review of a care plan, so that people can look at whether the services a person is receiving meet their needs and help them to achieve their goals.

Review

Details about a health and social care admission.

Admission details

Details about a health and social care setting discharge.

Discharge details

A record of a communication or correspondence, including the status such as preparation, completed, stopped etc.

Communication

A physical LOCATION.

This could be:
where a SUBJECT OF CARE is seen
where SERVICES exist
from which requests for ACTIVITIES are sent or
any other place of interest to an ORGANISATION which is not recorded as an ORGANISATION or an ORGANISATION_SITE.
For ACTIVITIES provided by staff groups, LOCATIONS are places where a face-to-face contact or a Group_Session occurs.

For diagnostic ACTIVITIES, LOCATIONS either define the whereabouts of the ACTIVITY or the places from which requests are sent.

Each LOCATION must be classified by one and only one type of LOCATION and the same classification must be used by all users.

Location

The identification of a place of relevance.

This could be to a:

PERSON
ORGANISATION
ORGANISATION_SITE or
LOCATION.
The ADDRESS may have COMMUNICATION_CONTACT_METHOD associated with it and may be the location for an ACTIVITY.

Address

Abstract class. Contains information that should be included as part of any event record e.g. plan, assessment, observation etc.

Event

Record of occupancy and availability for a given location.

Occupancy

Information recorded when a person interacts with health and social care services and concerning the management of a persons care and those responsible for caring for them.

Administrative information

The process of evaluating a person’s needs, wishes, strengths, preferences and mental capacity, as well as identifying any relevant risks associated with them.

Assessment

Written plans, after you have had an assessment, setting out what your care and support needs are, how they will be met (including what you or anyone who cares for you will do) and what services you will receive. The subject of care should have the opportunity to be fully involved in the plan and to say what their priorities are. If they are in a care home or attend a day service, the plan for their daily care may also be called a care plan.

Care plan

This is a record of the things that a person feels it is important to communicate about their needs, strengths, values, concerns and preferences to others providing support and care.

About me

Assessment and planning information records.

Assessment and planning

Information about when a record was created, modified, completed and authorised and by whom.

Change log

Every record must be versioned and include following information to identify each version. If records are immutable, then changes can be inferred by examining each version of the record. Otherwise if they are not immutable, a detailed change log must be captured for every update to the record.

Versioned record

Every record must be versioned and a log created for every change to a record.

Audit information

A person who seeks to receive, is receiving, or has received care.

Subject of care

Health and social care third party having person role with the right to take decisions on behalf of the subject of care.

Proxy for subject of care

The details of the subject of care’s personal contacts and information about the relationship between the subject of care and the person.

Personal contact

Abstract class. Contains information that should be included as part of any person record e.g. subject of care, proxy, personal contact

Person

Unpaid person who provides support or who looks after a family member, partner or friend who needs help because of their age, physical or mental illness, or disability.

Unpaid carer

Information about a care worker who provides care for the subject of care. Usually an employee of a provider, local authority, healthcare organisation or voluntary organisation.

Care worker

Organisation involved in providing care and support.

Care organisation

Organisation or person participating in health and adult social care

Care actor

Whether a decision has been made, the decision, 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

The voluntary and continuing permission of the person to receive particular treatment or care and support, based on an adequate knowledge of the purpose, nature, likely effects and risks including the likelihood of success, any alternatives to it and what will happen if the treatment does not go ahead. Permission given under any unfair or undue pressure is not consent. By definition, a person who lacks capacity to consent cannot consent to treatment or care and support, even if they cooperate with the treatment or actively seek it.

Informed consent

Details of the person's LPA record or equivalent

Lasting power of attorney

The framework of safeguards under the Mental Capacity Act 2005 for people who need to be deprived of their liberty in a hospital or care home in their best interests for care or treatment and who lack the capacity to consent to the arrangements made for their care or treatment.

Deprivation of Liberty Safeguards (DoLS) or equivalent

Details about a person diagnosed with a mental disorder, including where they are formally detained under the Mental health act or equivalent and the section number, or if a person is subject to Community Treatment Order or Conditional Discharge (or equivalent).

Mental health act or equivalent

Record of an advance decision to refuse one or more specific types of future treatment, made by a person who had capacity at the time of recording the decision. The decision only applies when the person no longer has the capacity to consent to or refuse the specific treatment being considered. An ADRT must be in writing, signed and witnessed. If the ADRT is refusing life-sustaining treatment it must state specifically that the treatment is refused even if the person's life is at risk.

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

Consent and legal information

Information about how care should be provided, including a set of planned / scheduled activities, as well as a record of the actions that have been completed and the outcomes of those actions.

Instruction

Defines a single activity within an Instruction, such as a medication administration.

Activity

Used to record an action that has been performed, which may have been ad hoc, or due to the execution of an Activity in an Instruction workflow.

Action

Instructions, activities and actions performed by care actors for the subject of care

Instructions, Activities, Actions

An incident that occurred in relation to care services resulting in unexpected or avoidable death, harm or injury to patient, carer, staff or visitor.

Incident

Used to record observed circumstances that impact a person’s health and wellbeing.

Circumstances

Healthcare problems associated with the Subject of care.

Problem

All health and care needs, including emotional, social, cultural, religious and spiritual needs, should be included in assessments about the care and treatment people receive.

Need

Risks identified as part of a risk assessment

Risk

A record of a person's aspirations and a description of things they want someone supporting them to do (or not to do)

Wish

A description of what is most important to a person, the people who are important to a person and things a person wants someone supporting them to do or not to do.

Preference

A description of strengths and assets the person has relating to their goals and hopes about their health and well-being.

Strengths

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.

Alert

Details about the Subject of care's allergies or adverse reactions.

Allergies and adverse reactions

Healthcare activity with the intention to clarify one or more health conditions of a subject of care. This can include a report which may have results for multiple tests.

Investigation result

End result, change or benefit for an individual who uses social care and support services.

Outcome

The overall goals, hopes, aims or targets that the person has. Including anything that the person wants to achieve that relates to their future health and wellbeing. Each goal may include a description of why it is important to the person. Goals may also be ranked in order of importance or priority to the person.

Goal

Identified safeguarding concerns protecting vulnerable people from neglect or physical, financial, psychological, verbal or other forms of abuse.

Implementation guidance: It is recognised that local authorities may not record the details of safeguarding concerns as a matter of policy. In such scenarios, health and social care organisations enquiring about a safeguarding flag may be directed to the local Multi-Agency Safeguarding Hub (MASH) team.

Safeguarding concern

Observation of activities relating to personal care and mobility about the home that are basic to daily living.

Daily living

A record of something a care actor has seen, heard, or noticed in reference to the health or social wellbeing of a person. These can include objective and subjective observations and can be recorded by healthcare professionals and/or other care actors.

Observations

The Adult Social Care Record Minimum Operational Data Standard (MODS) exists to ensure a consistent baseline record of direct care data by CQC registered adult social care providers. 

Adult Social Care Record (MODS)

Summary

Documentation

Origin