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The PRSB Standards for the Structure and Content of Health and Care Records is part of the on–going service to update and revise standards for care records which NHS Digital has commissioned from the Professional Record Standards Body (PRSB). This project was supported by the Royal College of Physicians Health Informatics Unit (RCP HIU).

The PRSB adopted the Academy of Medical Royal Colleges (AoMRC) “Standards for the Clinical Structure and Content of Patient Records”, published in 2013 when it was established in that same year. This release defines the structure and content of digital records based on a number of specified use cases (admission, referral, discharge, outpatient letter, and handover).

Since they were published further work has continued to develop more detailed structures and content for care records that support the transfer of structured, coded data and develop standards in other important areas such as crisis care. This further development has led to some additional structures being introduced for care records, some changes to their content and additional detail in the form of information models. This publication provides a single consistent set of current PRSB clinical record standards across all use cases to inform implementation in the NHS, in conjunction with NHS Digital technical specifications.

Copyright This document has been prepared by the Professional Record Standards Body on behalf of NHS Digital.

You may use and re–use the information presented in this document (not including logos or images) free of charge in any format or medium, under the terms of the Open Government Licence.

Any enquiry regarding the use and re–use of this information resource should be sent to: [email protected].

Where we have identified any third party copyright material you will need to obtain permission from the copyright holders concerned.

Information and content © NHS Digital 2018

NHS Digital 1 Trevelyan Square Boar Lane Leeds LS1 6AE www.digital.nhs.uk

Professional Record Standards Body 32–36 Loman Street London SE1 0EH www.theprsb.org

Royal College of Physicians 11 St Andrews Place London NW1 4LE www.rcplondon.ac.uk

Layout and design: Lucid Graphics

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Introduction 4

Why we need standards for digital health and care records 7

How we developed the standards 9

Using the standards 10

Section One: All record structured content 13

Section Two: Admission record 65

Section Three: Handover record 73

Section Four: Discharge record 80

Section Five: Outpatient letter 93

Section Six: Crisis care plan 104

Section Seven: Clinical referral information 111

Section Eight: Healthy child record 122

Section Nine: Digital care and support plan 138

Section Ten: Maternity record 142

Appendix One: Endorsement 164

Appendix Two: 2013 Structured content not currently used 165

Contents

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This publication is an essential resource that describes the standardised information that should be gathered and shared in health and care records so that the right data can flow digitally across health and social care to support the provision of high quality, timely and efficient care.

It provides a comprehensive description of the structure and content of health and care records. The standards cover transfer of care communications from referral information to admissions clerking, handover information sharing and discharge from acute settings including hospital or mental health services, emergency services, as well as outpatient letters. It also describes the structure and content of integrated health and care records including digital care and support plans, and child health records.

PRSB has revised and aligned its standards to support the digital exchange of health and care records and communications using technology called Fast Healthcare Interoperability Resources (FHIR). When put together, standardised care records and FHIR technology are a powerful combination that will allow information to flow directly from one IT system to another helping professionals to provide safe, high quality, timely and efficient care.

Publication of the 2018 PRSB Standards for the Structure and Content of Health and Care Records replaces the 2013 Standards for the Clinical Structure and Content of Patient Records.

The PRSB standards have been updated to reflect current professional practice and were developed with input from thousands of professionals from all health and social care specialties, carers and people who access services. They agreed what information is essential to share in order to provide timely, high quality care efficiently that is well–coordinated and meets an individual’s needs. The publication is being endorsed by PRSB member organisations – a list of endorsers can be found at Appendix One.

Introduction

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This is the first major release since 2013 and PRSB has produced guidance, FAQs and other materials to help organisations and system suppliers replace previous versions of the standards in their information systems.

This work forms part of the drive within the NHS and social care (Personalised Health and Care 2020) to improve the use of information and technology in order to:

• give patients more control over their health and well–being• empower carers• reduce the administrative burden for care professionals• support the wider use of information for research, service planning and

quality improvement

Rising demand for health and care, new models and ways of delivering services demand better information sharing. Safe, higher quality care depends on it as is evident from recent a report on the burden of prescribing errors and the Frances Report (www.gov.uk) in which better information sharing was cited as essential to the provision of safe care.

Professor Robert Wachter, in his landmark 2016 report Making IT Work (www.england.nhs.uk) concluded that if the NHS and social care are to continue to provide a high level of health and care at an affordable cost, we must create a fully digitised system that uses national standards as the basis upon which to build interoperability, transparency and efficiency. The development of local health and care record exemplars, global digital exemplars, and personalisation of health and care depend fundamentally on standards for information sharing as well.

The implementation of national standards for the structure and content of health and care records will facilitate shared care, enable interoperability between care settings, and produce comparable data to advance research and the life sciences, as well as improve management and planning of services and ultimately ensure clinicians, professionals and the people they care for reap the benefits of better quality services and outcomes of care.

Introduction

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In 2014 the NHS set out its vision to revolutionise the use of information and technology to improve health, transform the quality and reduce the cost of health and care services in Personalised Health and Care 2020. This included challenging targets for improving the flow of information between care settings by 2018. For information to be exchanged and re–used safely using digital technology it must be structured and standardised. Most importantly, the standards should reflect the ways that clinicians, professionals and patients value and share information to achieve the best outcomes of care possible. The PRSB was founded in 2013 (www.theprsb.org) to develop and maintain high quality health and care records to support safe and efficient care.

Beyond that the PRSB has a fundamental role to play in supporting other uses of information recorded in health and care records. These include research, quality improvement through audit and review, planning and management purposes, policy development, and commissioning care. Data must be fit for purpose and permissions for its use established. New legislation, the General Data Protection Regulations, and the National Data Opt Out for confidential patient information, are now in place to ensure information is well governed and consent is secured for wider use of data to advance improvements in care and treatments. Again, standards developed by the PRSB and its member organisations, working in partnership with the NHS and social care, are an essential underpinning to an individual’s health and care record from which the relevant information may be extracted for other important uses in the health and care system.

The government’s life sciences strategy and health and care research in general depend on high quality data being collected from large populations. The development of local health and care record exemplars not only will seek to address how information can be shared more effectively for direct care but also how data quality can be improved and linkages between data can be strengthened to address the health of specific populations, advance fields such as genomics and precision medicine, and yield new treatments and innovations. The possibilities of improving people’s quality of life and extending their lifespans are dramatic and national standards and definitions for care records have an important role to play in achieving these greatly desirable outcomes.

Why we need standards for digital health and care records

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PRSB standards are evidence–based and developed through a collaborative process that includes extensive consultation with the widest possible range of clinicians from the colleges and specialist societies, professionals who work in social care and informatics, system suppliers, patient representative groups and people who use health and social care services as well as carers. Consultations are undertaken via stakeholder workshops and online surveys, contributions number in the thousands for each standard produced.

The revised PRSB Standards for the Structure and Content of Health and Care Records build upon the 2013 Standards for the clinical structure and content of patient records and further work has been undertaken between December 2017 and April 2018 to align the clinical record standards to technical standards (FHIR profiles) necessary to ensure information can be shared interoperably from one IT system to another.

The work was undertaken in partnership with NHS Digital, INTEROPen and the Royal College of Physicians Health Informatics Unit.

For details of which organisations have endorsed the standards and which we are seeking further endorsement from please see Appendix One. The organisations listed demonstrate clinical and professional leadership in support of adoption and use of standards.

The standards consist of clinical, professional and patient–focused structured content including medications, allergies and diagnoses and a description of the information that should be recorded under each. The standards are presented at www.theprsb.org/standards using an easy to navigate tool as well as guidance on their use and other supporting documents.

For more information and help with queries please contact PRSB at [email protected].

How we developed the standards

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When using the standards, information should be recorded as structured content, which is divided into the following sections:

• All record structured content• Transfer of care• Integrated care

• All record structured content: this is the full set of structured recordcontent used in admission, handover, discharges, outpatient letters, referralcommunications and integrated care records. (Section One)

Transfers of care

• Admission record: the clinical, professional and personal informationrecorded in the hospital admission record at the time of admission.(Section Two)

• Handover record: handover of care from one professional or team to anotherincluding out of hours handover, or at the weekend. (Section Three)

• Discharge records: the information recorded in all discharge records sentfrom hospital services (including acute care discharge, mental healthdischarge and emergency care discharge) to GPs. (Section Four)

• Outpatient letters: the information recorded in an outpatient setting /appointment including the initial and follow up outpatient visits andinformation in the outpatient letter sent to the GP and patient. (Section Five)

• Crisis care: the information shared between GPs and primary care withemergency care, ambulance services and community care during anemergency or acute episode. (Section Six)

• Clinical referral information: the information recorded in communicationbetween GPs and consultants, copied to the patient. This may include othertypes of referrals. (Section Seven)

Using the standards

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Integrated care records

• Healthy child record: the information recorded by the multi–disciplinary teamon screening tests, immunisations and developmental milestones that should beaccessible to ensure that children receive appropriate care. (Section Eight)

• Digital care and support plan: the information recorded in a multi–disciplinarycare and support plan including clinical, professional as well as the patient’s ownpreferences and needs. (Section Nine)

• Maternity record: the structure and content for the health and care informationto be recorded in maternity services systems, GP systems and exchangedbetween different providers of maternity car, in order to improve the careexperienced by pregnant women and their babies. (Section Ten)

How to use

Not all the structured record content above will need to be used in all care settings or circumstances and the order in which it appears and how it is displayed in a digital patient record can be agreed by system suppliers and users.

Structured content that is not currently in use can be found at Appendix Two.

Using the standards

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All record structured content

© NHS Digital 2018

D: Acute Care DischargeM: Mental Health DischargeE: Emergency Care DischargeO: Outpatient Letter

C: Crisis Care PlanA: Admission RecordH: Handover R: Clinical Referral

HC: Healthy Child RecordCP: Digital Care and Support PlanMR: Maternity Record


The structure and content of all records are listed below – they are included in one or more of admission, handover, transfers of care and

integrated care records.

Not all structured content will be used in all care settings or circumstances and the order in which they appear in the electronic patient record,

communications and letters can be agreed by system suppliers and users.

(continued overleaf)

GP practice

Element Description

GP practice identifier The identifier of the registered GP practice.

GP practice details Name and address of the patient’s registered GP.

GP name Where the patient or patient’s representative offers the name of a GP as their usual GP.

GP Opt Out Indicator Indication that parent / carer or child has opted out of registering with a GP themselves.

1 1 1 1 1 1 1 1 1 1 1

1 1 1 1 1 1 1 1 1 1 1

1 1 1 1 1 1 1 1 1 1 1

0 0 0 0 0 0 0 0 0 1 1

D M E O C A H R HC CP MR

Referral details

Element Description

Referrer details The name, role, grade, organisation and contact details of referrer. If not an individual, this could be, e.g. GP surgery, department, specialty, sub–specialty, educational institution, mental health team etc. Also needs to include self–referral.

Date The date of the referral.

Referral method The form in which a referral is sent and received. This may be a letter, email, transcript of a telephone conversation, Choose and Book, in person (self–referral) or unknown.

Referral to The type of service or team that the patient has been referred into, e.g. GP surgery, department, specialty, subspecialty, educational establishment or mental health etc.

Speciality referred from The type of service or team that the patient has been referred from.

Urgency of referral Referrer’s assessment of urgency, e.g. urgent, soon or routine).

1 1 1 1 0 1 0 1 1 0 1

0 0 0 0 0 0 0 0 1 0 1

0 0 0 0 0 0 0 0 1 0 1

0 0 0 0 0 0 0 0 1 0 1

0 0 0 0 0 0 0 0 1 0 1

0 0 0 0 0 0 0 0 1 0 1


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Standards for patient records

© NHS Digital 2018

Element Description

Reason for referral A clear statement of the purpose of the person making the referral, e.g. diagnosis, treatment, transfer of care due to relocation, investigation, second opinion, management of the patient (e.g. palliative care), provide referrer with advice / guidance. This may include referral because of carer’s concerns.

Attachments Documents included as attachments which accompany the communication. This should include the following data items: • number of attachments• type of attachments• attached documents.

Details of other referrals Other referrals related to this or associated conditions.

Referral criteria Records whether specific criteria required for referral, to a particular service, have been met (may be nationally or locally determined).

Return response to The name of care professional to be communicated with by the hospital, if not the referrer.

0 0 0 0 0 0 0 0 1 0 1

0 0 0 0 0 0 0 1 0 0 0

0 0 0 0 0 0 0 1 0 0 0

0 0 0 0 0 0 0 1 0 0 0

0 0 0 0 0 0 0 1 0 0 0

Patient demographics

Element Description

Patient name The full name of the patient.

Patient preferred name The name by which a patient wishes to be addressed.

Date of birth The date of birth of the patient.

Gender As the patient wishes to portray themselves.

Person alias Record details where a person is known to use assumed identities to access health / care services.

Ethnicity The ethnicity of a person as specified by the person.

Religion The religious affiliation as specified by the person.

Sex The person’s phenotypic sex. This determines how the person will be treated clinically.

NHS number The unique identifier for a patient within the NHS in England and Wales.

Other identifier Country specific or local identifier, e.g. Community Health Index (CHI) in Scotland. Two data items: type of identifier and identifier.

Patient address The Patient’s usual place of residence.

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1 1 0 1 1 1 1 1 1 1 1

1 1 1 1 1 1 1 1 1 1 1

1 1 1 1 1 1 1 1 1 1 1

0 0 0 0 1 0 0 0 0 1 0

0 0 0 0 1 1 1 1 1 1 1

0 0 0 0 1 0 0 0 1 1 1

0 0 0 0 1 1 1 1 1 1 1

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Element Description

Patient email address The email address of the patient.

Patient telephone number The telephone contact details of the patient. To include, e.g. mobile, work and home number if available.

Relevant contacts Include the most important contacts such as: • Personal contacts, e.g. next of kin, in case of

emergency contact, lasting power of attorney,dependents and informal carers etc.

• Health / care professional contacts, e.g.social worker, hospital clinician, care coordinator,key worker or Independent Mental CapacityAdvocate (IMCA).

Name, relationship, role (if formal role), contact details and availability, e.g. out of hours.

Communication preferences The preferred contact method, e.g. sign language, letter and phone, etc. Also the preferred written communication format, e.g. large print, Braille.

Place of birth The town and country of birth of the patient.

Marital status An indicator to identify the legal marital status of the patient.

Date of death The date of death of the patient (if applicable).

Time of death The time of death of the patient (if applicable).

Educational establishment If the patient is a child, include the name and address of where the child attends, e.g. play group, nursery or school.

1 1 1 1 1 1 1 1 1 1 1

1 1 1 1 1 1 1 1 1 1 1

1 1 0 1 1 1 1 1 0 0 0

1 0 0 0 0 1 1 1 1 0 1

0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1

0 0 1 1 0 0 0 0 0 0 0


Social context

Element Description

Household composition E.g. lives alone, lives with family, lives with partner,etc. This may be free text.

Occupational history The current and / or previous relevant occupation(s) of the patient / individual.

Educational history The current and / or previous relevant educational history of the patient / individual.

1 1 0 1 1 1 1 1 1 0 1

1 1 0 1 0 1 0 1 0 0 0

1 1 0 1 0 0 0 1 0 0 1


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Element Description

Lifestyle The record of lifestyle choices made by the patient which are pertinent to his or her health and well–being, e.g. the record of the patient’s physical activity level, pets, hobbies, and sexual habits.

Smoking Current smoking observation.

Alcohol intake Latest or current alcohol consumption observation.

Drug / substance use Latest or current drug / substance use observation.

Social circumstances The record of a patient’s social background, network and personal circumstances, e.g. housing, religious, ethnic and spiritual needs, social concerns and whether the patient has dependents or is a carer. This may include a reference to safeguarding issues that are recorded elsewhere in the record.

Services and care The description of services and care providing support for the patient’s health and social well-being.

Access Special access requirements, e.g. key safe, coded lock, which door to use and stretcher access, etc.

Dependents Provide details of any responsibility the person has for dependents. In the case of minors, provide additional details, e.g. date of birth etc.

Accommodation status An indication of the type of accommodation where the child lives. This should be based on the main or permanent residence.

Family and household Family and household details of social context.

Father’s employment status The employment status of the father and his occupation.

Household social Whether or not any household member had / has services support social services support.

Household(s) environment Factors in the household(s) which impact the child’s health and well-being, to include smoking in the home, alcohol / substance use.

Asylum status The asylum status of the woman.

Number of years in education The number of years that the woman has spent in education.

Social risk factors A record of social factors which should be taken into account when providing care and support for the woman and the child when born.

Partner’s employment status The employment status of the Partner and their occupation.

0 0 0 1 0 1 0 1 1 0 1

0 0 0 1 0 1 0 1 1 0 1

0 1 0 1 0 1 0 1 1 0 1

0 1 0 1 0 0 0 1 1 0 1

0 0 0 1 0 1 0 1 1 0 1

0 0 0 1 1 1 0 1 0 0 0

0 0 0 0 1 0 0 0 0 0 0

0 0 0 0 1 0 0 0 0 0 0

0 0 0 0 0 0 0 0 1 0 1

0 0 0 0 0 0 0 0 1 0 1

0 0 0 0 0 0 0 0 1 0 0

0 0 0 0 0 0 0 0 1 0 1

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0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1


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Element Description

Mother’s employment status The employment status of the mother and her occupation.

Mother’s educational status The highest educational qualification attained by the child’s mother.

Other significant individuals Other significant individuals that do not live in the same household(s) but are deemed as key by the child’s family and / or the healthcare professional.

Personal Personal details of social context.

0 0 0 0 0 0 0 0 1 0 0

0 0 0 0 0 0 0 0 1 0 0

0 0 0 0 0 0 0 0 1 0 0

0 0 0 0 0 0 0 0 1 0 1


Individual requirements

Element Description

Individual requirements Individual requirements that a person has. These may be communication, cultural, cognitive or mobility needs.

Accessible information – Requirement for a communication professional requires communication to be present in order to provide accessibility, professional with regard to disability.

Accessible information – Outlines capability and support required in order communication support to provide accessibility, with regard to disability.

Accessible information – Requirement for a specific contact method in order requires specific contact to provide accessibility, with regard to disability. method

Accessible information – Requires information in a specific format in order to requires specific provide accessibility, with regard to disability. information format

Child or parent / carer / An indicator of whether the individual requirement guardian relates to the child or their primary carer.

Cognition An indicator of cognitive impairment to be considered when communicating related to the child or their primary carer.

Mobility needs A child or their primary carer’s personal physical movement between two spaces that achieves participation and a degree of independence.

1 1 0 1 1 1 1 1 1 0 1

0 0 0 0 0 0 0 0 1 0 1

0 0 0 0 0 0 0 0 1 0 1

0 0 0 0 0 0 0 0 1 0 1

0 0 0 0 0 0 0 0 1 0 1

0 0 0 0 0 0 0 0 1 0 0

0 0 0 0 0 0 0 0 1 0 1

0 0 0 0 0 0 0 0 1 0 1


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Participation in research

Element Description

Name of research study Name of the research study / trial and / or drug / intervention.

1 1 0 1 0 1 1 1 0 0 1


Attendance details

Element Description

Date and time of contact Date and time of the appointment, contact or attendance.

Contact type First contact, follow–up contact.

Consultation method The consultation method identifies the communication mechanism used to relay information between the care professional and the person who is the subject of the consultation, during the outpatient encounter.

Responsible healthcare The name and designation of the consultant, professional nurse consultant, midwife or allied health professional

who has overall responsibility for the patient (may not actually see the patient).

Speciality Specialties designated by royal colleges and faculties, e.g. orthopaedics, renal medicine, endocrinology, etc.

Service Treatment functions or services, e.g. hand surgery, back surgery, hand clinic, TIA clinic, falls clinic, speech and language therapy, dialysis, family therapy or pre–admission assessment clinic.

Location Details of where the contact was performed.

Location type An indication of the type of location where the contact took place e.g. woman’s home.

Seen by The doctor, nurse or other healthcare professional that sees the patient. Record the most senior member of staff present. Include their name, role and telephone number.

Care professionals present The name and designation of the additional individuals or team members including consultant(s), nurse consultant(s), allied health professional(s) and social worker(s).

Person accompanying Identify, where clinically relevant, others patient accompanying the patient, e.g. relative, friend,

informal carer or advocate. If the patient was not present, was an authorised representative present? Includes: name, relationship, role (patient advocate).

Outcome of outpatient This records the outcome of an out-patient attendance. attendance

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0 0 0 1 0 0 0 0 0 0 1

0 0 0 1 0 0 0 0 0 0 1

0 0 0 1 0 0 0 0 0 0 0

0 0 0 1 0 0 0 0 0 0 1

0 0 0 1 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1

0 0 0 1 0 0 0 0 0 0 1

0 0 0 1 0 0 0 0 0 0 1

0 0 0 1 0 0 0 0 0 0 1

0 0 0 1 0 0 0 0 0 0 1


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Admission details

Element Description

Reason for admission The health problems and issues experienced by the patient that prompted the decision to admit them to hospital, e.g. chest pain, mental health crisis, blackout, fall, a specific procedure, intervention, investigation, treatment or non compliance with treatment.

Admission method How the patient was admitted to hospital, e.g. elective, emergency, maternity or hospital transfer.

Legal status on admission Record if the patient was admitted as informal or formal / detained.

Source of admission Where the patient was immediately prior to admission, e.g. usual place of residence, temporary place ofresidence, penal establishment. National code.

Date / time of admission Date and time the patient was admitted to hospital.

Patient location This is the physical location of the patient. For inpatient, e.g. hospital ward, bed or theatre. For ambulatory care, e.g. health centre, clinic, resources centre or patient’s home.

Responsible consultant The name and designation of the consultant, who has overall responsibility for the patient (may not actually see the patient).

Person accompanying Identify others accompanying the patient, e.g. patient relative, friend, informed carer or advocate. If the

patient was not present, was an authorised representative present? Include their name, relationship (e.g. spouse) and role (e.g. patient advocate).

Speciality Specialties designated by royal colleges and Faculties, e.g. orthopaedics, renal medicine and endocrinology.

Admitted to The ODS site code and description of where the child was admitted.

1 1 0 0 0 1 1 0 1 0 1

1 1 0 0 0 1 0 0 1 0 1

0 1 0 0 0 0 0 0 0 0 0

1 1 0 0 0 1 0 0 1 0 1

1 1 0 0 0 1 1 0 1 0 1

0 0 0 0 0 1 1 0 0 0 0

0 0 0 0 0 1 1 0 1 0 1

0 0 0 0 0 1 0 0 1 0 1

0 0 0 0 0 1 0 0 1 0 1

0 0 0 0 0 0 0 0 1 0 1


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Discharge details

Element Description

Discharge destination The destination of the patient on discharge. unit National codes, e.g. high dependency.

Discharge status The patient’s status on discharge from emergency care.

Discharging consultant The consultant responsible for the patient at the time of discharge.

Discharging specialty / The specialty or department responsible for the department patient at the time of discharge.

Discharge location The ward or unit the patient was in immediately prior to discharge.

Date / time of discharge The date and time of discharge.

Legal status on discharge Record if the patient was discharged as informal or formal / detained.

Discharge method The method of discharge from hospital. Use national codes, e.g. patient discharged on clinical advice or with clinical consent, patient discharged him / herself or was discharged by a relative or advocate, patient died or stillbirth.

Discharge destination comprising:

Discharge type The destination of the patient on discharge from hospital. Use national codes e.g. NHS–run care home.

Discharge address The patient’s discharge address. Only complete where this is not the usual place of residence.

Expected date of discharge The date when the patient is currently expected to be discharged from hospital.

0 0 1 0 0 0 0 0 1 0 1

0 0 1 0 0 0 0 0 0 0 0

1 1 0 0 0 0 0 0 1 0 1

1 1 0 0 0 0 0 0 1 0 1

1 1 0 0 0 0 0 0 1 0 1

1 1 1 0 0 0 0 0 1 0 1

0 1 0 0 0 0 0 0 0 0 0

1 1 0 0 0 0 0 0 1 0 1

1 1 0 0 0 0 0 0 0 0 0

1 1 0 0 0 0 0 0 0 0 0

1 1 0 0 0 0 0 0 1 0 1

0 0 0 0 0 1 1 0 0 0 0


Relevant clinical risk factors

Element Description

Relevant clinical risk factor Factors that have been shown to be associated with the development of a medical condition being considered as a diagnosis / differential diagnosis, e.g. being overweight, smoker, no use of sun screenor an enzyme deficiency.

Date The date on which the clinical risk factor was recorded.

Location The location where the clinical risk factor was recorded.

Performing professional Details of the professional recording the clinical risk factor (including name and role)

0 0 0 1 0 1 1 1 1 0 1

0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1


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Presenting complaints or issues

Element Description

Presenting complaint The health problem or issue experienced by the or issue patient resulting in their attendance. This may

include disease state, medical condition, response and reactions to therapies, e.g. blackout, dizziness, chest pain, follow up from admission, falls, a specific procedure, investigation or treatment.

0 0 1 0 0 0 0 0 0 0 0


Element Description

Clinical risk assessment Specific risk assessments required / undertaken.

Risk mitigation Action taken to reduce the clinical risk and date actions.

Patient at high risk This patient is at high risk of clinical deterioration and will need an immediate response if called.

0 0 0 1 0 1 1 1 1 0 1

0 0 0 1 0 1 1 1 1 0 1

0 0 0 0 0 0 1 0 0 0 0


Problems and issues

Element Description

Date recorded The date on which the problem was recorded.

Performing professional Details of the professional recording (including name and role).

Location Details of where the problem was recorded.

Problem A condition which needs addressing and so is important for every health professional to know about when seeing the woman. Problems may include diagnoses, symptoms, disabilities and social or behavioural issues, and comprise the ‘Problem list’.

Date A date or estimated date that the problem began.

End Date The date or estimated date the problem was resolved (will be blank for active).

Stage of disease The stage of the disease where relevant.

0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1

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0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1



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Element Description

Problems and issues Summary of problems that require investigation or treatment. This would include significant examination findings, symptoms and signs, which are likely to have relevance and are not a diagnosis.

Clinical risks Description of clinical risks identified, e.g. problematic intubation, person with brittle diabetes, immunocompromised or risk of infection etc.

Comment Any further textual comments to clarify, such as a statement that information is partial or incomplete.

0 0 0 1 1 1 1 0 1 0 0

0 0 0 0 1 0 0 0 1 0 0

0 0 0 0 0 0 0 0 1 0 0


Diagnosis

Element Description

Diagnosis Confirmed diagnosis and symptoms or active diagnosis being treated.

Stage The stage of the disease or disorder, where relevant.

Comment Supporting text may be given covering diagnosis confirmation, active diagnosis being treated. Include severity, occurrence (first, recurrence, ongoing).

Awareness of diagnosis The description of the level of awareness the person and their carer / family has regarding their diagnosis.

Date diagnosis made The date when the diagnosis was made.

1 1 1 1 1 0 1 0 1 0 0

1 1 0 1 0 0 0 0 1 0 0

1 1 1 1 0 0 0 0 1 0 0

0 0 0 0 1 0 0 0 0 0 0

0 0 0 0 0 0 0 0 1 0 0


History

Element Description

Patient’s reason for referral The patient’s stated reason for referral. This may include any discussions that took place, the level of shared decision making involved, information about the patient’s source of advice. This may be expressed on behalf of the patient, e.g. by a parent or carer.

Presenting complaints The list and description of the health problems and or issues issues experienced by the patient resulting in the attendance. This may include disease state, medical condition, response and reaction to therapies, e.g. blackout, dizziness, chest pain, follow–up from admission, falls, a specific procedure, investigation or treatment.

0 0 0 1 0 0 0 1 0 0 0

0 0 1 1 0 1 0 1 0 0 0


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Element Description

History of each presenting Information directly related to the development and complaint or issue characteristics of each presenting complaint (e.g. including travel history). Including if the information is given by the patient or their carer.

History since last contact History since last attendance, discharge from hospital, etc.

Relevant past medical, The record of the person’s significant medical, surgical and mental surgical and mental health history. Including relevant health history previous diagnoses, problems and issues, procedures, investigations and specific anaesthesia issues. (will include dental and obstetric history).

Reason for referral A clear statement of the purpose of the person making the referral, e.g. diagnosis, treatment, transfer of care due to relocation, investigation, second opinion, management of the patient (e.g. palliative care), provide referrer with advice / guidance. This may include referral because of carers’ concerns.

Expectation of referral A clear statement of the expectations of the person making the referral as to the management of the patient, e.g. advice only, diagnosis and treatment.

Patient’s expectation The patient‘s expectations of the referral including of referral preferences. This may include any discussions that took place, the level of shared decision making involved and information about patient’s source of advice.

Management to date Referrals, management, investigations and treatment that have already been undertaken, including the patient managing their own symptoms. This may include any procedures conducted with the date and procedure report.

Urgency of referral The referrer’s assessment of urgency, e.g. urgent, soon or routine. This may include the reason if other than routine. E.g. two data items: • level of urgency • reason.

Reason for admission The health problems and issues experienced by the patient resulting in their referral by a healthcare professional for hospital admission, e.g. chest pains blackouts, falls, a specific procedure, investigation or treatment.

Information brought The information brought by the patient, e.g. patient by patient passport, example diary data, pre–completed questionnaires, person–held maternity record, or personal child health record.

0 0 0 1 0 1 0 1 0 0 0

0 0 0 1 0 0 0 0 0 0 0

0 0 0 1 1 1 1 1 0 0 0

0 0 0 0 0 0 0 1 0 0 0

0 0 0 0 0 0 0 1 0 0 0

0 0 0 0 0 0 0 1 0 0 0

0 0 0 0 0 0 0 1 0 0 0

0 0 0 0 0 0 0 1 0 0 0

0 0 0 0 0 1 0 0 0 0 0

0 0 0 0 0 1 0 0 0 0 0


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Procedures

Element Description

Date The date on which the procedure was recorded.

Location The location where the procedure was recorded.

Performing professional Details of the professional performing the procedure (including name and role).

Procedure The therapeutic or diagnostic procedure performed.

Anatomical site The body site of the procedure.

Laterality The laterality of the procedure.

Complications related Details of any intra–operative complications to procedures encountered during the procedure, arising during the patient’s stay in the recovery unit or directly attributable to the procedure.

Specific anaesthesia issues Details of any adverse reaction to any anaesthetic agents including local anaesthesia. Which may include problematic intubation or transfusion reaction.

Comment Any further textual comments to clarify, such as a statement that information is partial or incomplete.

0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1

1 1 1 1 0 0 0 0 0 0 1

1 1 1 1 0 0 0 0 0 0 1

1 1 1 1 0 0 0 0 0 0 1

1 1 1 1 0 0 0 0 0 0 1

1 1 1 1 0 0 0 0 0 0 1

1 1 1 1 0 0 0 0 0 0 1


Clinical summary

Element Description

Clinical summary A summary of the encounter. Where possible, this should be very brief. This may include interpretation of findings and results such as: differential diagnoses, opinion and specific action(s). Planned actions will be recorded under ‘plan’.

Formulation An account, shared by a therapist and person, of the personal meaning and origins of a person’s difficulties. This is viewed in the context of multiple factors including relationships, social circumstances and life events and will indicate the most helpful way forward.

Treatments and The relevant treatments and interventions which the interventions and changes patient received during the inpatient stay. Include made to treatments. psychological therapies. All medications should be recorded under the medications section.

Clinical narrative A description detailing a patient’s reason for attendance, results from the diagnostic and treatment process.

1 1 1 1 0 1 1 0 0 0 0

0 1 0 0 0 0 0 0 0 0 0

0 1 0 0 0 0 0 0 0 0 0

0 0 1 0 0 0 0 0 0 0 0


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Family history

Element Description

Family history The record of relevant illness in family relations deemed to be significant to the care or health of the patient, including mental illness and suicide, genetic information etc.

Condition or diagnosis The condition or diagnosis in family relations deemed to be significant to the care or health of the child.

Date The date the family history was recorded.

Maternal or paternal relation Record of whether the condition or diagnosis was on the mother’s or father’s side of the family, where needed e.g. paternal grandfather.

Relationship to patient The relationship of the person with the condition to the patient.

Comment Any further textual comment.

0 1 0 1 0 1 0 1 1 0 1

0 0 0 0 0 0 0 0 1 0 1

0 0 0 0 0 0 0 0 1 0 1

0 0 0 0 0 0 0 1 1 0 1

0 0 0 0 0 0 0 1 1 0 1

0 0 0 0 0 0 0 1 1 0 1


Investigation results

Element Description

Date The date on which the investigation was performed.

Performing professional Details of the professional performing the investigation (including name and role).

Location The location where the investigation was recorded.

Investigation The investigation performed.

Investigation result For each investigation, the result of the investigation (this includes the result value, with unit of observation and reference interval where applicable and date, and plans for acting upon investigation results).

0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1

0 0 0 1 0 0 0 1 0 0 1

1 1 0 1 0 1 1 1 0 0 1


Assessment scales

Element Description

Assessment scale Structured assessment scales used as part of assessment and treatment, e.g. New York Heart Failure, Activities of Daily Living (ADL).

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Element Description

Assessment scale name The name of the overarching assessment scale used e.g. Bayley, Griffiths, Ages & Stages Questionnaire etc.

Comment Supporting text may be given regarding the assessment scale as a whole or a subscale.

Date The date on which the assessment scale was recorded.

Global score The total global score from the assessment.

Location The location where the assessment scale was recorded.

Performing professional Details of the professional performing the assessment scale (including name and role).

Subscale name The name of the subscale used (where relevant).

Subscale score The total subscale score from the assessment.

0 0 0 0 0 0 0 0 1 0 1

0 0 0 0 0 0 0 0 1 0 1

0 0 0 0 0 0 0 0 1 0 1

0 0 0 0 0 0 0 0 1 0 1

0 0 0 0 0 0 0 0 1 0 1

0 0 0 0 0 0 0 0 1 0 1

0 0 0 0 0 0 0 0 1 0 1

0 0 0 0 0 0 0 0 1 0 1


Safeguarding

Element Description

Safeguarding concerns A record of any identification of concerns regarding safeguarding during attendance.

Date The date on which safeguarding details were recorded

Location The location where the safeguarding details were recorded

Performing professional Details of the professional recording the safeguarding details (including name and role)

Comment A comment providing further detail on a safeguarding concern.

0 0 1 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1

0 0 1 0 0 0 0 0 0 0 1


Safety alerts

Element Description

Risks to self Risks the patient poses to themselves, e.g. suicide, overdose, self–harm or self–neglect.

Risks to others Risks to caring professionals or others.

Risk from others Details of where an adult or child is at risk from an identified person, e.g. a family member.

Date The date on which the safety alert was recorded.

1 1 1 1 1 1 0 1 1 0 1

1 1 1 1 1 1 0 1 1 0 1

1 1 1 1 1 1 0 1 1 0 1

0 0 0 0 0 0 0 0 1 0 1


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Element Description

Location The location where the safety alert was recorded.

Performing professional Details of the professional recording the safety alert (including name and role).

0 0 0 0 0 0 0 0 1 0 1

0 0 0 0 0 0 0 0 1 0 1


Allergies and adverse reactions

Element Description

Causative agent The agent such as food, drug or substances that has caused or may cause an allergy, intolerance or adverse reaction in this patient. Or “no known drug allergies or adverse reactions” or “information not available”.

Description of reaction A description of the manifestation of the allergic or adverse reaction experienced by the patient. For example, skin rash.

Severity A description of the severity of the reaction.

Certainty A description of the certainty that the stated causative agent caused the allergic or adverse reaction.

Type of reaction The type of reaction experienced by the patient (allergic, adverse, intolerance).

Evidence Results of investigations that confirmed the certainty of the diagnosis. Examples might include results of skin prick allergy tests.

Date first experienced The date when the reaction was first experienced. This may be a date or partial date (e.g. year) or text (e.g. during childhood).

Comment Any additional comment or clarification about the adverse reaction.

Date recorded The date that the reaction was clinically recorded / asserted. This will often equate to the date of onset of the reaction but this may not be wholly clear from source data.

Probability of recurrence Probability of the reaction (allergic, adverse, intolerant) occurring.

1 1 1 1 1 1 1 1 1 0 1

1 1 1 1 1 1 1 1 1 0 1

1 1 1 1 0 0 0 0 1 0 1

1 1 1 1 0 0 0 0 1 0 1

1 1 0 1 0 0 0 0 1 0 1

1 1 0 1 0 0 0 0 1 0 1

1 1 0 1 0 1 1 1 1 0 1

1 1 1 0 0 0 0 0 1 0 1

1 1 0 0 0 0 0 0 1 0 1

1 1 0 1 0 1 1 1 1 0 1


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Patient concerns, expectations and wishes

Element Description

Patient concerns, Description of the concerns, wishes or goals of the expectations and wishes person in relation to their care, as expressed by the person, their representative or carer. Record who has expressed these (patient or carer / representative on behalf of the patient). Where the person lacks capacity this may include their representative’s concerns, expectations or wishes.

Date The date on which the concerns, wishes or goals of the woman were recorded.

Maternity Care Plan Type The stage of maternity to which the care plan applies e.g. antenatal.

Planned delivery setting The planned delivery setting where the pregnant woman plans to have her baby as designated by the Care Professional in consultation with the woman.

Reason for change of The reason why the planned delivery setting has changed. planned delivery setting

Advance statement Written requests and preferences made by a person with capacity conveying their wishes, beliefs and values for their future care should they lose capacity. Include the location of the document if known.

Preferred place of care The preferences that a person has identified as their preferred place to receive care.

Preferred place of death The preferences that a person has identified as their preferred place to die.

1 1 0 1 1 1 1 1 1 0 1

0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1

1 1 0 1 1 0 0 0 0 0 1

0 0 0 0 1 0 0 0 0 0 0

0 0 0 0 1 0 0 0 0 0 0


Crisis care plan

Element Description

Care funding details A record of the funding source and any conditions or limitations associated.

Priorities of care 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.

Estimated prognosis Where a person is terminally ill this is a clinical judgment indicating the anticipated period of time until death. This could be their last days, weeks, months or year of life. Also include the date the prognosis was made.

0 0 0 0 1 0 0 0 0 0 0

0 0 0 0 1 0 0 0 0 0 0

0 0 0 0 1 0 0 0 0 0 0


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Element Description

Awareness of prognosis Description of the level of awareness the person and / or their carer / family has regarding their estimated prognosis.

Anticipatory actions Please provide guidance on specific interventions or actions that may be required or should be avoided in specific situations.

Anticipatory Medicines or equipment available in the event of a medicines / equipment crisis and their location.

Agreed with person or Indicates whether the crisis care plan was legitimate representative discussed and agreed with the person or legitimate representative. If agreement cannot be obtained the reason for this should be documented.

Cardio–pulmonary Please state here whether a decision has been resuscitation (CPR) decision 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.

Planned review date The date the plan is due for review.

0 0 0 0 1 0 0 0 0 0 0

0 0 0 0 1 0 0 0 0 0 0

0 0 0 0 1 0 0 0 0 0 0

0 0 0 0 1 0 0 0 0 0 0

0 0 0 0 1 0 0 0 0 0 0

0 0 0 0 1 0 0 0 0 0 0


End of life

Element Description

Certification of death If the person is in their last weeks of life, is there a doctor who has seen the person recently who could potentially sign a death certificate? Provide contact details.

Actions taken in The plan that has been agreed to facilitate certification anticipation of death of death and / or funeral arrangements, e.g. anticipatory discussions with coroner to arrange funeral within 24 hours.

Actual place of death The location where the person actually died as recorded on the death certificate. If the person died somewhere other than their preferred place, record the reasons why this happened.

Cause of death The cause of death as recorded on the death certificate.

Date of death The date on which a person died or is officially deemed to have died, as recorded on the death certificate.

0 0 0 0 1 0 0 0 0 0 0

0 0 0 0 1 0 0 0 0 0 0

0 0 0 0 1 0 0 0 0 0 0

0 0 0 0 1 0 0 0 0 0 0

0 0 0 0 1 0 0 0 0 0 0


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Clinical review of symptoms

Element Description

Clinical review of systems The clinical review of systems. The record of clinical information gathered in responses to questions to the patient about specific symptoms from various physiological systems, including food intake (increasing / decreasing) weight change and swallowing difficulties etc.

0 0 0 1 0 1 0 0 0 0 0


Information and advice given

Element Description

Information and This includes: advice given • what information • to whom it was given. • the oral or written information or advice given to the patient, carer, other authorised representative, care professional or other third party. This may include advice about actions related to medicines or other ongoing care activities on an ‘information prescription’. State here if there are concerns about the extent to which the patient and / or carer understand the information provided about diagnosis, prognosis and treatment.

Date The date on which the information and advice was given.

Location Details of where the information and advice was given.

Performing professional Details of the professional giving the information and advice (including name and role).

1 1 1 1 0 1 1 1 1 0 1

0 0 0 0 0 0 0 0 1 0 1

0 0 0 0 0 0 0 0 1 0 1

0 0 0 0 0 0 0 0 1 0 1


Person completing record

Element Description

Name The name of the person completing the record, preferably in a structured format.

Role The role the person is playing within the organisation at the time record was updated.

Grade The grade of the person completing the record.

Specialty The main specialty of the person completing the record.

1 1 1 1 1 1 0 1 0 0 0

1 1 0 1 1 1 0 1 0 0 0

1 1 0 1 0 1 0 1 0 0 0

1 1 0 1 0 1 0 1 0 0 0


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Element Description

Professional identifier Professional identifier for the person completing the record, e.g. GMC number, HCPC number etc. or the personal identifier used by the local organisation.

Date and time completed The date and time the record was updated.

Contact details Contact details of the person completing the record. For example a phone number, email address. Contact details are used to resolve queries about the record entry.

Organisation The organisation the person completing the record works for.

1 1 1 1 1 0 0 0 0 0 0

1 1 0 1 1 0 0 1 0 0 0

1 1 0 1 1 0 0 0 0 0 0

1 1 0 0 1 0 0 0 0 0 0


Senior reviewing clinician

Element Description

Name The name of the senior clinician responsible for reviewing the patient treatment and discharge plan.

Professional identifier The unique identifier issued by the regulatory body, e.g. GMC number, HCPC number etc.

0 0 1 0 0 0 0 0 0 0 0

0 1 1 0 0 0 0 0 0 0 0


Contact for further information

Element Description

Contact for further The contact details of whom to contact for information information regarding this attendance.

0 0 1 0 0 0 0 0 0 0 0


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Distribution list

Element Description

Name If the communication is being sent to a named individual, then this is the name of the recipient, preferably in a structured format. An identifier for the individual, for example GMC code (for a GP), or an SDS identifier, a NHS number (for a patient) will be sent alongside the name, but may not displayed on rendered document.

Role If the communication is being sent to either a named individual, or to a non–named person with a specific role, then this is the role of the recipient.

Grade The recipient’s grade.

Organisation name The name of the organisation the recipient is representing or the organisation named as the receiving organisation. An identifier for the organisation will be sent alongside the name, but may not displayed on rendered document.

Team Team that the recipient belongs to in the context of receiving this message, or the team acting as the recipient.

Relationship to subject The relationship of the receiver to the patient, where the receiver has a personal relationship to the patient, for example, carer or parent.

1 1 0 1 0 0 0 1 0 0 0

1 1 0 1 0 0 0 1 0 0 0

1 1 0 1 0 0 0 1 0 0 0

1 1 0 1 0 0 0 1 0 0 0

1 1 0 1 0 0 0 1 0 0 0

1 1 0 1 0 0 0 1 0 0 0


Birth details

Element Description

APGAR score A set of observations made on the baby following birth to check adaptation to life outside the womb. This includes 1 minute, 5 minutes and 10 minutes.

Birth order The sequence in which this baby was born (one of one, one of two etc.).

Birth weight Numeric value for weight at birth.

Date & Time of birth The date and time of birth of the baby.

Delivery place type The type of place in which the baby was born, e.g. private health facility, domestic address, NHS hospital, midwifery led unit etc.

Fetal problems diagnosed Problems with the fetus diagnosed with screening before birth or ultrasound. e.g. Down syndrome, congenital heart disease etc.

Length of gestation Gestational age in weeks and days (usually equivalent to length of pregnancy).

0 0 0 0 0 0 0 0 1 0 1

0 0 0 0 0 0 0 0 1 0 1

0 0 0 0 0 0 0 0 1 0 1

0 0 0 0 0 0 0 0 1 0 0

0 0 0 0 0 0 0 0 1 0 0

0 0 0 0 0 0 0 0 1 0 0

0 0 0 0 0 0 0 0 1 0 1


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Element Description

Location of birth The place of birth (including the address and organisation name where relevant).

Maternal problems in Maternal medical conditions or infectious pregnancy diseases arising in pregnancy which may have an impact on the fetus, e.g. gestational diabetes, rubella etc.

Multiple birth Where the baby is one of a multiple birth, to include the total number of offspring and to include whether the baby is identical to one of the siblings.

Neonatal resuscitation Details of neonatal resuscitation measures required, e.g. chest compression, oxygen mask etc.

Physical problems Physical problems identified with the baby at, or detected at birth shortly after, birth, e.g. cleft lip / palate, extensive bruising, cephalohematoma etc.

Name The given name as recorded by the midwife

NHS number The unique identifier for a woman within the NHS in England and Wales.

Baby identifier Baby identifier details.

Gender The person’s phenotypic sex. Determines how the person will be treated clinically.

Birth outcome The birth outcome of each fetus.

Rhesus status An indication of whether the fetus has or does not have the rhesus factor (or Rh D antigen) on the surface of their red blood cells, using the Rh System.

Congenital abnormalities (Yes no field) as per NHSDD and recorded on Birth Notification.

Investigations requested To include any investigations requested including post mortem investigations).

Problems during delivery Problems experienced by the baby during delivery, e.g. cord prolapse, meconium aspiration, fetal distress etc.

Put to breast Whether or not the baby was put to the breast.

Spontaneous respiration Details of neonatal resuscitation measures required, e.g. chest compression, oxygen mask etc.

Type of delivery Type of delivery for the baby, e.g. vacuum extraction, breech extraction, elective caesarean section etc.

Types of delivery The type(s) of delivery for the baby that was (attempted) attempted, but was not the final delivery method.

0 0 0 0 0 0 0 0 1 0 0

0 0 0 0 0 0 0 0 1 0 0

0 0 0 0 0 0 0 0 1 0 1

0 0 0 0 0 0 0 0 1 0 0

0 0 0 0 0 0 0 0 1 0 0

0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 1 0 0

0 0 0 0 0 0 0 0 1 0 0

0 0 0 0 0 0 0 0 1 0 0

0 0 0 0 0 0 0 0 1 0 0

0 0 0 0 0 0 0 0 1 0 0


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Demographic history

Element Description

Date of birth History of date of birth changes.

Gender History of gender change.

Patient address History of Patient’s usual place of residence.

Patient name Any previous names, aliases and preferred name. This will normally be given by a patient demographics service (PDS) patient trace, or the name of the patient held on the local patient administration system (PAS).

Patient telephone number History of telephone contact details of the patient. To include, e.g. mobile, work and home number if available.

0 0 0 0 0 0 0 0 1 0 1

0 0 0 0 0 0 0 0 1 0 1

0 0 0 0 0 0 0 0 1 0 1

0 0 0 0 0 0 0 0 1 0 1

0 0 0 0 0 0 0 0 1 0 1


Developmental skills

Element Description

Date first achieved The date the developmental skill was first achieved (developmental first) as reported by the parent. This is primarily for parent reporting as part of parent child health record at the time the skill is acquired.

Date of enquiry The date the parent or carer was asked by a health professional about the developmental skill (milestone).

Date of observation The date a health professional observed or tested a developmental skill (milestone).

Developmental skill The name of the developmental skill (e.g. walks independently, smiles, finger feeds etc.).

Result of enquiry Whether the developmental skill was achieved, not achieved or equivocal.

Result of observation Whether the developmental skill was achieved, not achieved or equivocal.

Comments Supporting text may be given regarding the developmental skill.

0 0 0 0 0 0 0 0 1 0 0

0 0 0 0 0 0 0 0 1 0 0

0 0 0 0 0 0 0 0 1 0 0

0 0 0 0 0 0 0 0 1 0 0

0 0 0 0 0 0 0 0 1 0 0

0 0 0 0 0 0 0 0 1 0 0

0 0 0 0 0 0 0 0 1 0 0


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Educational history

Element Description

Educational assessment The outcome of an educational assessment.

Educational establishment Name of educational establishment.

Type of educational Phase / type of education establishment. establishment

Type of special The type of special educational needs for the child. educational need

Year from The year the child attended the school from.

Year to The year the child left the school.

0 0 0 0 0 0 0 0 1 0 0

0 0 0 0 0 0 0 0 1 0 0

0 0 0 0 0 0 0 0 1 0 0

0 0 0 0 0 0 0 0 1 0 0

0 0 0 0 0 0 0 0 1 0 0

0 0 0 0 0 0 0 0 1 0 0


Emergency care attendance

Element Description


Date and time of Date and time patient arrived at the unscheduled attendance care unit.

Date and time of discharge The actual date and time of discharge.

Diagnosis Confirmed diagnosis; active diagnosis being treated. Include the stage of the disease where relevant.

Discharge destination The destination of the patient on discharge. National codes, e.g. High Dependency Unit.

Discharge status Patient status on discharge from emergency care.

Location Details of where the unscheduled care attendance took place.

Person accompanying Identify others accompanying the patient, e.g. patient relative, friend, patient informal carer, advocate. If the patient was not present, was an authorised representative present. Include name and relationship (friend, relative, etc.).

0 0 0 0 0 0 0 0 1 0 0

0 0 0 0 0 0 0 0 1 0 0

0 0 0 0 0 0 0 0 1 0 0

0 0 0 0 0 0 0 0 1 0 0

0 0 0 0 0 0 0 0 1 0 0

0 0 0 0 0 0 0 0 1 0 0

0 0 0 0 0 0 0 0 1 0 0

0 0 0 0 0 0 0 0 1 0 0



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Feeding status

Element Description

Date The date the feeding status was recorded.

Date breast milk Date of last breast milk feed to the nearest month feeding stopped and year.

Feeding concerns A record of any concerns about the baby’s feeding.

Feeding method A record of the predominant feeding method for the baby, e.g. breast fed, bottle / cup fed, gastronomy, nasogastric feeds etc.

First milk feed Whether or not the baby’s first feed was breast milk.

Introduction of solids Whether the baby has been introduced to solid foods at the time seen.

Milk feeding status Whether the baby is totally breast milk fed, of the baby partially breast milk fed or not breast milk fed. To be recorded each time a baby has contact with a health professional.

0 0 0 0 0 0 0 0 1 0 0

0 0 0 0 0 0 0 0 1 0 0

0 0 0 0 0 0 0 0 1 0 0

0 0 0 0 0 0 0 0 1 0 0

0 0 0 0 0 0 0 0 1 0 0

0 0 0 0 0 0 0 0 1 0 0

0 0 0 0 0 0 0 0 1 0 0


Element Description

Plan and requested actions A simple free text description of the plan of action following the contact with the child. This may include actions for the parent, healthcare professional (e.g. health visitor) and review.

Presenting complaint The health problem or issue experienced by the or issue patient resulting in their attendance. This may include disease state, medical condition, response and reactions to therapies, e.g. blackout, dizziness, chest pain, follow up from admission, falls, a specific procedure, investigation or treatment.

Procedure The therapeutic or diagnostic procedure performed on the patient. This may be coded, or represented as free text.

Referral source Source of referral for unscheduled care.

Safety alerts Safety alerts at the emergency care attendance suggested to be pulled through from the safety alerts heading.

0 0 0 0 0 0 0 0 1 0 0

0 0 0 0 0 0 0 0 1 0 0

0 0 0 0 0 0 0 0 1 0 0

0 0 0 0 0 0 0 0 1 0 0

0 0 0 0 0 0 0 0 1 0 0


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Health and well-being assessment and reviews

Element Description


Post Birth Review This details those checks and assessments done on the baby prior to leaving hospital that do not make up the NIPE screening.

New baby review The details captured as part of the new baby review.

6–8 week health The details captured as part of the 6–8 heath visitor review visitor review.

1 year review The details captured as part of the 1 year review.

2–2 1 / 2 year health and The details captured as part of the 2–2 1 / 2 health development review and development review.

School entry review The details captured as part of the school entry review including the outcome of the hearing and screening check.

Ad–hoc health review The details captured as part of any ad–hoc health review undertaken.

0 0 0 0 0 0 0 0 1 0 0

0 0 0 0 0 0 0 0 1 0 0

0 0 0 0 0 0 0 0 1 0 0

0 0 0 0 0 0 0 0 1 0 0

0 0 0 0 0 0 0 0 1 0 0

0 0 0 0 0 0 0 0 1 0 0

0 0 0 0 0 0 0 0 1 0 0

0 0 0 0 0 0 0 0 1 0 0


Immunisations

Element Description

Batch number The batch number of the vaccine.

Date The date on which the Immunisation was administered.

Dose amount Amount of vaccine administered.

Dose sequence Nominal position in a series of vaccines.

Indication The clinical indication or reason for administering the immunisation.

Location Details of where the immunisation was performed.

Manufacturer The vaccine manufacturer.

Name of immunisation Which immunisation has been administered (SNOMED CT code – list of available immunisations).

Outcome status Whether the vaccine was administered or not, including the reason why.

0 0 0 0 0 0 0 0 1 0 1

0 0 0 0 0 0 0 0 1 0 1

0 0 0 0 0 0 0 0 1 0 1

0 0 0 0 0 0 0 0 1 0 1

0 0 0 0 0 0 0 0 1 0 1

0 0 0 0 0 0 0 0 1 0 1

0 0 0 0 0 0 0 0 1 0 1

0 0 0 0 0 0 0 0 1 0 1

0 0 0 0 0 0 0 0 1 0 1



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Measurements

Element Description

BMI centile Child BMI centile calculated using the height / weight / gender and age of the child.

Date The date on which the measurement was recorded.

Head circumference Numeric value for the head circumference.

Height / length Numeric value for the body length.

Location The location where the measurement was recorded.

Performing professional Details of the professional performing the measurement (including name and role).

Weight Numeric value for weight.

0 0 0 0 0 0 0 0 1 0 0

0 0 0 0 0 0 0 0 1 0 0

0 0 0 0 0 0 0 0 1 0 0

0 0 0 0 0 0 0 0 1 0 0

0 0 0 0 0 0 0 0 1 0 0

0 0 0 0 0 0 0 0 1 0 0

0 0 0 0 0 0 0 0 1 0 0


National screening programme

Element Description

Newborn blood spot The details captured as part of the NBS programme Screening which screens for sickle cell disease (SCD), cystic fibrosis (CF), congenital hypothyroidism (CHT) and inherited metabolic diseases (IMDs).

Newborn hearing screening The details captured as part of the NHSP programme which offers 2 types of test for babies: • automated otoacoustic emission (AOAE) • automated auditory brainstem response (AABR).

0 0 0 0 0 0 0 0 1 0 0

0 0 0 0 0 0 0 0 1 0 0


Element Description

Performing professional Details of the professional performing the immunisation (including name and role).

Reported A flag to indicate the information was reported to a healthcare professional.

Route How vaccine entered the body.

Site Body site vaccine was administered into.

Vaccine product Vaccine product administered.

0 0 0 0 0 0 0 0 1 0 1

0 0 0 0 0 0 0 0 1 0 1

0 0 0 0 0 0 0 0 1 0 1

0 0 0 0 0 0 0 0 1 0 1

0 0 0 0 0 0 0 0 1 0 1


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Element Description

Newborn and infant The details captured as part of the NIPE physical examination programme which tests babies within 72 hours (72 hours) of birth for conditions relating to their: • heart • hips • eyes • testes.

Newborn and infant The details captured as part of the NIPE programme physical examination which tests babies again at 6–8 weeks for conditions (6–8 weeks) relating to their: • heart • hips • eyes • testes.

National screening programme The overarching screening programme. e.g. – NHS Fetal Anomaly Screening Programme – NHS Infectious Diseases in Pregnancy Screening Programme – NHS Sickle Cell and Thalassaemia Screening Programme.

Specific test performed The specific screening test performed, e.g. combined test, quadruple test, HIV, Syphilis etc. This may include site and laterality where applicable.

Screening test outcome The overall outcome of the screening test (this may include the status e.g. declined, deferred etc.).

Comments Supporting text may be given regarding the screening test, outcome and actions taken.

National antenatel screening programme

NHS fetal anomaly screening The details captured as part of the NHS Fetal programme – Down’s, Edwards’ Anomaly Screening Programme which screens and Patau’s Syndromes. for Down’s, Edwards’ and Patau’s syndromes.

NHS fetal anomaly screening The details captured as part of the NHS Fetal programme – structural Anomaly Screening Programme which screens anomalies for fetal anomalies.

NHS infectious diseases The details captured as part of the NHS Infectious in pregnancy screening Diseases in Pregnancy Screening Programme programme which screens for Hepatitis B, HIV and Syphilis via a blood test. Chlamydia for under 25s and Hepatitis C can be recorded here as required.

NHS Sickle Cell and The details captured as part of the NHS Sickle Cell Thalassaemia screening and Thalassaemia Screening Programme which programme screens to find out if the woman is a carrier of the sickle cell or thalassaemia gene and therefore likely to pass it on to the baby. This may also be applicable to the baby’s father if the woman is identified as a carrier of a haemoglobin disease.

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0 0 0 0 0 0 0 0 1 0 0

0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1



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Parent / guardian / personal comment

Element Description

Date Date the comment was entered and shared.

Who Who recorded the comment and what relationship they are to the child.

Parent/guardian or Free text comment made by the parent/ personal comment guardian of the child, or the child themselves.

0 0 0 0 0 0 0 0 1 0 0

0 0 0 0 0 0 0 0 1 0 0

0 0 0 0 0 0 0 0 1 0 0


Personal contacts

Element Description

Name The name of the person.

Relationship The personal relationship the individual has to the child (e.g. father, grandmother, family friend etc.).

Parental responsibility Flag to indicate whether the personal contact has parental responsibility.

Household member Status identifying whether the personal contact is a member of the same household.

Next of Kin The primary person to contact in the event of an emergency or other situation.

Contact details Contact details of the person (e.g. telephone number, email address etc.).

NHS number The NHS number of the personal contact.

0 0 0 0 0 0 0 0 1 0 1

0 0 0 0 0 0 0 0 1 0 1

0 0 0 0 0 0 0 0 1 0 1

0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 1 0 1

0 0 0 0 0 0 0 0 1 0 1


Professional contacts

Element Description

Name / team The name of the person or the team responsible.

Role The professional role the individual has in relation to the child, e.g. nursery nurse, health visitor, school nurse etc.

0 0 0 0 0 0 0 0 1 0 1

0 0 0 0 0 0 0 0 1 0 1


Element Description

NHS diabetic eye The details captured as part of the NHS screening programme diabetic eye screening programme which is offered to women with diabetes in pregnancy.

0 0 0 0 0 0 0 0 0 0 1


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Reason for referral

Element Description


Clinical urgency of referral Referrer’s assessment of urgency, (e.g. urgent / soon / routine), may include reason if other than routine, e.g. two data items: • level of urgency • reason.

Expectation of referral A clear statement of the expectations of the person making the referral as to the management of the patient, e.g. advice only, diagnosis, treatment, etc. To Include any specific patient expectation In general text. Risk not put in a procedure not already received.

Presenting complaints The list and description of the health problems or issues and issues experienced by the patient precipitating referral. This may include disease state, medical condition, response and reaction to therapies, e.g. blackout, dizziness, chest pain, follow–up from admission, falls, a specific procedure, investigation, family history or treatment.

0 0 0 0 0 0 0 1 0 0 0

0 0 0 0 0 0 0 1 0 0 0

0 0 0 0 0 0 0 1 0 0 0

0 0 0 0 0 0 0 1 0 0 0


Element Description

Speciality The specialty of the professional responsible, e.g. health visiting, school nursing etc.

Team The name of the team, if the name of the person has been entered.

Organisation The name of the organisation responsible.


Start date The start date of the relationship with the health professional.

End date The end date of the relationship with the health professional.

0 0 0 0 0 0 0 0 1 0 1

0 0 0 0 0 0 0 0 1 0 1

0 0 0 0 0 0 0 0 1 0 1

0 0 0 0 0 0 0 0 1 0 1

0 0 0 0 0 0 0 0 1 0 1

0 0 0 0 0 0 0 0 1 0 1


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About me

Element Description

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

Date This is a record of the date that this information was last updated.

Supported to write this by Where relevant, this is a record of name, relationship / role and contact details of the person who supported the individual to write this section, e.g. carer, family member, advocate, professional.

0 0 0 0 0 0 0 0 0 1 0

0 0 0 0 0 0 0 0 0 1 0

0 0 0 0 0 0 0 0 0 1 0


Element Description

History of each presenting Information directly related to the development complaint or issue and characteristics of each presenting complaint, (e.g. including travel history). Including if the information is given by the patient or their carer.

Management to date Referrals, management, investigations and treatment that have already been undertaken, including patient managing their symptoms. Including: • procedures conducted – procedures carried out (and the date) and procedure report.

0 0 0 0 0 0 0 1 0 0 0

0 0 0 0 0 0 0 1 0 0 0


Contingency plan(s)

Element Description

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

Anticipatory Medicines or equipment available that may be medicines / equipment required in specific situations and their location.

Contingency plan name Name of the contingency plan – what condition or circumstances it is addressing.

Date this plan was This is a record of the date that this contingency last updated plan was last updated.

Planned review date / interval This is the date/interval when this contingency plan will next be reviewed.

Responsibility for review This is a record of who has responsibility for arranging review of this information. Should include their name, role and contact details.

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0 0 0 0 0 0 0 0 0 1 0

0 0 0 0 0 0 0 0 0 1 0

0 0 0 0 0 0 0 0 0 1 0

0 0 0 0 0 0 0 0 0 1 0

0 0 0 0 0 0 0 0 0 1 0


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Outstanding issues

Element Description

Tasks which must be done Include time-scales (appropriate seniority of staff for each task).

Tasks to be done if possible E.g. test review, pre–discharge documents, criteria for discharge, including who may discharge the patient.

0 0 0 0 0 0 1 0 0 0 0

0 0 0 0 0 0 1 0 0 0 0


Person handing over

Element Description






0 0 0 0 0 0 1 0 0 0 0

0 0 0 0 0 0 1 0 0 0 0

0 0 0 0 0 0 1 0 0 0 0

0 0 0 0 0 0 1 0 0 0 0

0 0 0 0 0 0 1 0 0 0 0


Element Description

Trigger factors Signs to watch out for that may indicate a significant change in health or other circumstances.

What should happen To record guidance on specific actions or interventions that may be required or should be avoided in specific situations. This may include circumstances where action needs to be taken if a carer is unable to care for the individual.

Who should be contacted Who should be contacted in the event of significant problems or deterioration in health or well-being including, e.g. name, designation and contact details of persons.

0 0 0 0 0 0 0 0 0 1 0

0 0 0 0 0 0 0 0 0 1 0

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Handover details

Element Description

Patient location This is the physical location of the patient. For inpatient, e.g. hospital ward, bed, theatre. For ambulatory care, e.g. health centre, clinic, resources centre, patient’s home.

Planned patient location If patient is changing location.

Date of admission Date patient admitted to hospital.

Expected date of discharge The date the patient is currently expected to be discharged from hospital.


Specialty Specialties designated by royal colleges and faculties, e.g. orthopaedics, renal medicine, endocrinology, etc.

Service Subspecialties, treatment functions or services, e.g. hand surgery, back surgery, hand clinic, TIA clinic, falls clinic, speech and language therapy, dialysis, family therapy, pre–admission assessment clinic etc.

Date of decision to handover Date decision made to handover care.

New responsible consultant The name and designation of the consultant who is accepting responsibility for the patient’s inpatient care.

Date handover accepted Date decision made to accept handover of care.

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0 0 0 0 0 0 1 0 0 0 0

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0 0 0 0 0 0 1 0 0 0 0

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Person receiving handover

Element Description

Name The name of the person receiving the handover, preferably in a structured format.

Role The role the person is playing within the organisation at the time of handover.

Grade The grade of the person receiving the handover.

Specialty The specialty of the person receiving the handover.

Contact details Contact details of the person receiving the handover. For example a phone number, email address. Contact details are used to resolve queries about the record entry.

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Element Description

Reason for handover A clear statement of the reason for the temporary or permanent handover of care, e.g. low potassium, immediately post–op, unstable medical condition.

Senior clinical contact If there is a particular requirement to call a specific person, e.g. consultant, SpR or special intervention team.

0 0 0 0 0 0 1 0 0 0 0

0 0 0 0 0 0 1 0 0 0 0


Additional supporting plan(s)

Element Description

Additional supporting The name of the particular additional supporting plan name plan, e.g. dietician’s plan, wound management plan, discharge management plan.

Additional support This is the content of any additional care and support plan content plan which the individual and / or care professional consider should be shared with others providing care and support. It should be structured as recommended for the care and support plan and if contains additional detail, it may be referenced here.

Person completing record This is the person contributing to the care and support plan. Should include their name, role, grade, specialty, organisation, professional identifier, date and time completed, contact details.

Planned review date / interval This is the date / interval when this information will next be reviewed.


Date this plan was last updated This is a record of the date that this information was last updated.

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0 0 0 0 0 0 0 0 0 1 0

0 0 0 0 0 0 0 0 0 1 0

0 0 0 0 0 0 0 0 0 1 0

0 0 0 0 0 0 0 0 0 1 0

0 0 0 0 0 0 0 0 0 1 0


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Care and support plan

Element Description

Actions and activities Actions or activities the individual or others plan to take to achieve the individual’s goals and the resources required to do this. For each action the following may be identified: Stage goal – a specific sub–goal that is related to the overall goal as agreed by the person in collaboration with a professional What – what the action is and how it is to be carried out? Who – name and designation, e.g. person, carer, GP, OT, etc., of the person, or a team, carrying out the proposed action, and, if relevant where action should take place When – planned date, time, or interval, as relevant Suggested strategies for potential problems Status – not started, started, completed, not applicable Confidence – how confident the person feels to carry it out Outcome – the outcome of the stage goal Date when action / activity record was last updated Review date – when the stage goal and action need to be reviewed.

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

Care funding source A reference to the funding source and any conditions or limitations associated.

Date last updated Date when action / activity record was last updated.

Date this plan was last updated This is a record of the date that this care and support plan was last updated.

Goals and hopes The overall goals, hopes, aims or targets that the individual has. Anything they want to achieve that relates to their future health and well-being. 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 individual.

Needs, concerns or Needs, concerns or health problems an individual has health problems that relate to their health and well–being.

Other care planning documents Reference other care planning documents, including the type, location and date. This may include condition–specific plans, advance care plans, end of life care plan, etc.

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Legal information

Element Description

Consent for treatment record Whether consent has been obtained for the treatment. May include where record of consent is located or record of consent.

Consent for information sharing This is a record of consent for information sharing under the common law duty of confidentiality. Where consent has not been obtained or sought, the reason why should be provided. Include best interests decision where person lacks capacity.

Consent relating to child Consideration of age and competency, applying Gillick competency or Fraser guidelines. Record of person with parental responsibility or appointed guardian where child lacks competency. Record if there is disagreement between patient and parent.

Parental responsibility For children this is a record of person(s) with parental responsibility.

Mental capacity assessment Whether an assessment of the mental capacity of the (adult) person has been undertaken, if so, what capacity the decision relates to, who carried it out, when and the outcome of the assessment. Also record best interests decision if person lacks capacity.

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1 1 0 1 1 1 1 1 0 0 1

1 0 0 1 0 1 1 1 0 0 0

0 0 0 0 1 0 0 0 0 0 0

1 1 0 1 0 1 1 1 0 0 1


Element Description

Outcomes Outcomes of each of the individual’s goals, aims and targets. Includes comments recorded by the individual, date and status: fully achieved, partially achieved, not achieved, on–going, no longer applicable.



Strengths Any strengths and assets the individual has that relate to their goals and hopes about their health and well–being.

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0 0 0 0 0 0 0 0 0 1 0

0 0 0 0 0 0 0 0 0 1 0

0 0 0 0 0 0 0 0 0 1 0



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Element Description

Lasting power of attorney Record of one or more people who have been for personal welfare or given power (LPA) by the person when they had court-appointed deputy capacity to make decisions about their health and (or equivalent) welfare should they lose capacity to make those decisions. To be valid, an LPA must have been registered with the Court of Protection. If life-sustaining treatment is being considered the LPA document must state specifically that the attorney has been given power to consent to or refuse life-sustaining treatment. Details of any person (deputy) appointed by the court to make decisions about the person’s health and welfare. A deputy does not have the power to refuse life-sustaining treatment.

Deprivation of Liberty Record of Deprivation of Liberty Safeguards Safeguards or equivalent (DoLS) or equivalent, including the reason for this.

Mental Health Act Record where a person diagnosed with a mental or equivalent status disorder is formally detained under the Mental Health Act or equivalent, including the section number and start date, start time and end date. If person subject to Community Treatment Order or Conditional Discharge (or equivalent) record here.

Advance decision to A record of an advance decision to refuse one refuse treatment (ADRT) 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.

Safeguarding issues Any legal matters relating to safeguarding of a vulnerable child or adult, e.g. child protection plan, protection of vulnerable adult.

Organ and tissue donation Whether the person has given consent for organ and / or tissue donation or opted out of automatic donation where applicable. The location of the relevant information / documents.

Consent for creation of Separate explicit consent is required for creation of end of life care plan an end of life care record. This records how this consent has been granted in order to differentiate between person’s explicit consent, best interest decision, lasting power of attorney decision and withdrawal of consent.

Looked after child The details of whether the child is a ‘looked after child’

Child protection plan The details of the child’s protection plan

Local authority The named local authority.

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Plan and requested actions

Element Description

Actions Including planned investigations, procedures, Interventions and treatment for a patient’s identified conditions and priorities. For each action the following should be identified: a) person responsible – name and

designation / department / hospital / patient etc. orrole (e.g. GP) responsible for carrying out the proposedaction, and where action should take place.

b) status – requested, planned or completed.c) When action requested for – requested date, time,

or period – as relevant.d) suggested strategies – suggested strategies for

potential problems.e) outcome expectations, including patient’s expectations.

Actions for healthcare Including planned investigations, procedures and professionals treatment for a patient’s identified conditions and

priorities. For each action the following should be identified: outcome expectations, including patient’s expectations

Actions for patient or For each action the following should be identified: their carer expectations outcome expectations, including patient’s

Agreed with patient Indicates whether the patient or legitimate or legitimate patient representative has agreed the entire plan or representative individual aspects of treatment, expected outcomes,

risks and alternative treatments.

Care planning arrangements Record if CPA (Care Programme Approach) documentation is available and how and where it can be accessed; care and treatment plan in Wales and Scotland. In Wales this is superseded by the Mental Health Measure 2010.

Special monitoring required E.g. neuro–obs, 02 saturation etc.

Aims and limitations of The current aim of treatment including limitations to treatment and special treatment and communications issues, e.g. not for ITU. instructions

Escalation plan Who needs to be contacted in the event of significant problems or patient deterioration include, e.g. seniority / name / contact details of person to be called.

Investigations requested This includes a name or description of the investigation requested and the date requested.

Procedures requested These are the diagnostic or therapeutic procedures that have actually been requested (and the date requested).

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1 1 1 0 1 1 0 0 0 0 1

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Element Description

Date The date on which the plan and requested actions was recorded.

Performing professional Details of the professional performing the plan and requested actions (including name and role).

0 0 0 0 0 0 0 0 1 0 1

0 0 0 0 0 0 0 0 1 0 1


Medical history

Element Description

Date The date on which the medical history was recorded.

Location The location where the medical history was recorded.

Performing professional Details of the professional performing the medical history (including name and role).

Gynaecology 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.

Past obstetric A record of the woman’s obstetric medical history relevant to the maternity episode. To include each previous pregnancy details and the outcome.

Relevant past medical history The record of the patient’s significant medical, history. Including relevant previous diagnoses, health history problems and issues.

Relevant past surgical history The record of the patient’s significant surgical history. Including relevant issues, procedures, investigations, specific anaesthesia issues, etc.

Relevant past mental A record of the woman’s mental health history health history relevant to the maternity episode.

Acute hospital episodes Reported details of any history of acute hospital episodes including ITU, HDU and A&E attendances the woman has had.

Mental health admissions Reported details of any history of mental health admissions.

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Examination findings

Element Description

Examination The examination performed, e.g. general appearance, vital signs, mental state, head and neck examination, oral examination, cardiovascular system, respiratory system, abdomen, genitourinary, nervous system, musculoskeletal system, skin. This could include site and must include laterality where applicable.

Examination findings The record of findings from the examinations performed.

Vital signs The record of essential physiological measurements, e.g. heart rate, blood pressure, temperature, pulse, respiratory rate, SpO2, level of consciousness etc. Use of Early Warning Score (which may be computed) chart where appropriate.

Performing professional Details of the professional performing the examination (including name and role).

Location The location where the examination was recorded.

Date The date on which the examination was recorded.

General appearance The record of a clinician’s ‘first impression’ assessment including general clinical examination finding, e.g. clubbing, anaemia, jaundice, obese / malnourished / cachectic, height, weight, etc.

Observations The record of essential physiological measurements, e.g. heart rate, blood pressure, temperature, pulse, respiratory rate, oxygen saturation. Use of National Early Warning Score (NEWS) chart where appropriate.

Mental health examination The record of findings from mental health examinations and, where appropriate, the type of the examination.

Head and neck examination The record of findings from the head and neck examination.

Oral examination The record of findings from the oral examination.

Cardiovascular examination The record of findings from the cardiovascular system examination.

Respiratory examination The record of findings from the respiratory system examination.

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Element Description

Obstetric and Gynaecology The record of findings from the obstetric examination examination (including e.g. abdominal uterine palpation, striations or Linea abdominal and Nigra and whether she has previous operative scars, uterine palpation) such as previous caesarean section. To include the record of findings from the vaginal examination, including FGM, presentation, moulding, membranes, observation of liquor and general cervical observations and contractions (including the strength, length and frequency), uterus size etc.

Neurological system examination The record of findings from the neurological system examination.

Musculoskeletal examination The record of findings from the musculoskeletal examination.

Dermatology examination The record of findings from the examination of the skin.

Abdomen examination The record of findings from the abdominal examination.

Genitourinary examination The record of findings from the genitourinary examination.

Comments Supporting text may be given regarding the examination.

Fetal examinations To be recorded one per fetus

Fetal movements To be completed for each fetus and includes the examination of fetal movements, fetal heart rate, summary of CTG baseline (bpm) and decelerations.

Presenting part The presenting part of the fetus.

Lie The lie of the fetus.

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Personal comment / plan

Element Description

Date The date on which the comment was entered and shared.

Person details Who recorded the comment and what relationship they are to the woman.

Personal comment Free text comment recorded by the woman or her representative.

Maternity personalised Personalised care plan details to include the data care plan and plan details.

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Pregnancy episode details

Element Description

Pregnancy ID Identifier used to tie together data relating to a specific pregnancy, allowing specific contacts and activities carried out (e.g. scans, tests, observations, findings, diagnoses) to be linked back to the booking appointment for that pregnancy.

Fetal identifier Identifier which allows woman babies to be identified in the event of multiple births, and in turn allow specific conditions to be attributed to specific babies and linked to labour / antenatal test details.

Maternity episode start date The start date of the maternity episode.

Maternity episode end date The end date of the maternity episode.

Maternity episode end reason The reason that the woman was discharged from maternity services.

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0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1


Pregnancy outcome delivery and birth

Element Description

Date The date on which the pregnancy outcome / delivery / birth details were recorded.

Location The location where the pregnancy outcome / delivery / birth details was recorded.

Performing professional Details of the professional recording the pregnancy outcome / delivery / birth details (including name and role).

Pregnancy outcome The pregnancy outcome of each fetus.

Birth

Labour onset method Details of the method by which the process of labour began, or delivery by caesarean section occurred.

Date and time of The date / time when established labour is established labour confirmed – regular painful contractions and progressive cervical dilatation.

Date and time fully dilated The date and time that the woman is deemed to be fully dilated.

Duration of 1st stage A derived field based on the time of established labour to the time of full dilation.

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0 0 0 0 0 0 0 0 0 0 1

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Element Description

Onset of 2nd Stage of labour The date and time that the second stage of labour was deemed to start.

Date and time The date and time that pushing commenced. pushing commenced


Delivery place type The type of place in which the baby was born (e.g. Private health facility, domestic address, NHS hospital, midwifery led unit etc.) .

Birth attendants People present at the delivery.

Ruptured membranes Date / time on which membranes ruptured date / time if spontaneous.

Duration of rupture The duration in hours and minutes as derived of membranes using the date of rupture versus current date time.

Anaesthesia type The specific type of anaesthesia used to carry out the procedure (if applicable).

Pain relief A record of pain relief used during labour and delivery where not anaesthetic or medication.

Delivery decision date / time The date and time of the decision to deliver.

Delivery decision made by The details of the clinician making the decision to deliver.

Reason for delivery decision The details of the reason for the decision to deliver.

Date and time of delivery The date and time of the delivery of the baby.

Duration of second stage Derived field from the onset of the second stage to the date and time of delivery.

Types of delivery (attempted) The type(s) of delivery for the baby that was attempted, but was not the final delivery method.

Type of delivery Type of delivery for the baby, e.g. spontaneous vaginal, vacuum extraction, breech extraction, elective caesarean section etc.

Length of labour The length of the stages of labour and duration of the rupture of membranes (derived field).

Delayed cord Record the duration of which cord clamping occurred. Clamping / duration

Placenta delivery method The method by which the placenta was removed through physiological, active or manual means. Where more than one method is used, the final method should be recorded.

End of third stage The date and time of the end of the third stage of labour.

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0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1


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Element Description

Third stage duration The duration of the third stage of labour derived between the start of the third stage and the delivery of the placenta.

Examination of placenta A visual examination of the placenta to check completeness.

Placenta disposal The method by which the placenta was disposed.

Placenta sent for histology An indication as to whether the placenta was sent for histology.

Umbilical cord number The number of umbilical cord vessels. of vessels

Total blood loss The total volume of blood loss in mls following delivery.

Comments Supporting text may be given covering regarding the outcome of the checks and actions taken.

0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1


Scan details

Element Description

Date The date on which the scan was performed.

Performing professional Details of the professional performing the scan (including name and role).

Location The location where the scan was recorded.

Scan The type of scan performed.

Scan finding For each pregnancy scan, the finding of the scan (this includes the result value, with unit of observation and reference interval where applicable.

Comment Supporting text may be given regarding the scan.

0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1


Professional comment

Element Description

Date The date on which the professional summary / comment was recorded.

Location The location where the professional summary / comment was recorded.

0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1



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Medications and medical devices

Element Description

Medication name May be generic name or brand name (as appropriate).

Form E.g. capsule, drops, tablet, lotion etc.

Route Medication administration description (oral, IM, IV, etc.): may include method of administration, (e.g. by infusion, via nebuliser, via NG tube).

Quantity supplied The quantity of the medication (e.g. tablets, inhalers, etc.) provided to the patient on discharge. This may be dispensed by the pharmacy or on the ward.

Site The anatomical site at which the medication is to be administered, e.g. “left eye”.

Method The technique or method by which the medication is to be administered.

Dose amount description A description of the medication single dose amount, e.g. “30 mg” or “2 tabs”.

Dose timing description A description of the frequency of taking or administration of a medication dose, e.g. “twice a day”, “at 8am 2pm and 10pm”.

Dose directions description A single plain text phrase describing the entire medication dosage and administration directions including dose quantity and medication frequency, e.g. “1 tablet at night or “2mg at 10pm”. This is the form of dosage direction text normally available from UK GP systems.

Additional instructions Allows for: • requirements for adherence support, e.g. compliance aids, prompts and packaging requirements • level of urgency additional information about specific medicines, e.g. where specific brand required • person requirements, e.g. unable to swallow tablets.

Indication Reason for medication being prescribed, where known.

Comment / recommendation Suggestions about duration and / or review, ongoing monitoring requirements, advice on starting, discontinuing or changing medication.

1 1 1 1 1 1 0 1 1 0 1

1 1 1 1 1 1 0 1 1 0 1

1 1 1 1 1 1 0 1 1 0 1

1 1 1 1 1 1 0 1 0 0 1

1 1 1 1 1 1 0 1 0 0 1

1 1 1 1 1 1 0 1 0 0 1

1 1 1 1 1 1 0 1 0 0 1

1 1 1 1 1 1 0 1 0 0 1

1 1 1 1 0 0 0 1 1 0 1

1 1 1 1 1 1 0 1 1 0 1

1 1 1 1 1 1 0 1 1 0 1

1 1 1 1 1 1 0 1 1 0 1


Element Description

Performing professional Details of the professional performing the professional summary / comment (including name and role).

Professional summary Summary of the encounter. Where possible, very brief. This may include interpretation of findings and results, opinion and specific action(s). Planned actions will be recorded under ‘plan’.

0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1


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Element Description

Dose direction duration Recommendation of the time period for which the medication should be continued, including direction not to discontinue.

Performing professional Details of the professional administering the medication (including name and role).

Location Details of where the medication was administered.

Date The date on which the medication was administered.

Parsable dose directions A parsable ‘dose syntax’ which carries dose strength, dose timing, dose duration and maximum dose information, e.g. “20-30mg ^4 / 6h prn [180mg / 24h]” = 20 to 30 mgs, up to 4-6 hourly as required. Maximum 180mg in 24 hours. The ‘as required reason’ e.g. ‘for pain’ should be carried in the Additional Instruction element. Note that this is generally a symptom and is not the same as the Indication which will usually describe a diagnosis or condition. Where supported, this would generally be used to exchange dosage information between systems, while Structured dose directions are likely to be used only within open EHR-based systems.

Structured dose A structural representation of the elements carried direction cluster by the dose syntax in ‘Parsable dose Strength / timing’ i.e. dose strength, dose timing, dose duration and maximum dose.

Structured dose amount cluster A structural representation of dose amount, e.g. 20mg or 2 tablets This element will generally only be used when persisting data within systems with ‘parsable dose directions’ being used to exchange the same information between systems.

Structured dose timing cluster A slot containing a structural, computable representation of dose timing and maximum dose. This element will generally only be used when persisting data within systems with ‘Parsable dose directions’ being used to exchange the same information between systems.

Start date / time The date and / or time that the medication course should begin.

End date / time The date and / or time that the medication course should finish.

Authorised date Date prescriber created prescription.

Request for advice Request for advice and recommendation about medication.

1 1 1 0 0 1 0 1 1 0 1

0 0 0 0 0 0 0 0 1 0 1

0 0 0 0 0 0 0 0 1 0 1

0 0 0 0 0 0 0 0 1 0 1

0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 1 0 1

0 0 0 0 0 0 0 0 1 0 1

0 0 0 0 0 0 0 1 0 0 1

0 0 0 0 0 0 0 1 0 0 0



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Element Description

Valid from date Date the prescription can be issued from. Valid for 6 months.

Course details cluster

Course status The status of this prescription in an ambulatory (out patient / GP / community) context.




Link to indication record A link to the record which contains the Indication for this medication order.


Medication change summary cluster

Status The nature of any change made to the medication since admission.

Indication Reason for change in medication, e.g. sub-therapeutic dose, woman intolerant.

Date of latest change The date of the latest change – addition, or amendment.

Description of amendment Where a change is made to the medication i.e. one drug stopped and another started or e.g. dose, frequency or route is changed.

Comment Any additional comment about the medication change

Total dose daily quantity cluster The total daily dose of this medication. This is helpful for estimating optimal adherence to dosing guidance. It may be computed from product / dose strength and frequency or entered manually.

Quantity supplied The quantity of the medication (e.g. tablets, inhalers, etc.) provided to the woman on discharge. This may be dispensed by the pharmacy or on the ward.

Medication discontinued entry

Name of discontinued medication The name of the medication or medical device being discontinued.


0 0 0 0 0 0 0 1 0 0 1

1 1 1 1 1 0 0 0 1 0 1

1 1 1 1 1 0 0 0 1 0 1

1 1 1 1 1 0 0 0 1 0 1

1 1 1 1 1 0 0 0 1 0 1

1 1 1 1 1 0 0 0 1 0 1

1 1 1 1 1 0 0 0 1 0 1

1 1 1 1 1 0 0 0 1 0 1

1 1 1 1 1 0 0 0 1 0 1

1 1 1 1 1 0 0 0 1 0 1

1 1 1 1 1 0 0 0 1 0 1

1 1 1 1 1 0 0 0 1 0 1

1 1 1 1 1 0 0 0 1 0 1

1 1 1 1 1 0 0 0 1 0 1

1 1 1 1 1 0 0 0 1 0 1

1 1 1 1 1 0 0 0 1 0 1


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Element Description

Indication The clinical indication for any changes in medication status.

Date of latest change The date of the discontinuation.

Description of amendment A description of any amendment.

Comment Any additional comment about the medication change.

Use the following heading for medical devices that do not have representation in the NHS dictionary of medicines and medical devices (dm+d):

Medical devices Any therapeutic medical device of relevance that does not have representation in the NHS dictionary of medicines and medical devices (dm+d).

Repeat medications: This is the sub–section where all current repeat medications are recorded.

Medication name Mandatory medication name coded using SNOMED CT / dm+d term where possible, allowing plain text for historical / patient reported items, extemporaneous preparations or those not registered in dm+d.

Form Form of the medicinal substance, e.g. capsules, tablets, liquid. Not normally required unless a specific form has been requested by the prescriber, e.g. “modified release capsules”.

Route Optional medication route, using SNOMED CT terms where possible. Not generally applicable to product– based medication. Should not be used to specify a specific administration site, for which a separate archetype is used, e.g. the route is ‘intraocular’ the site may be ‘left eye’, e.g. “oral”, “intraocular”. Note that this element supports multiple routes to allow a choice to be specified by the prescriber.



Dose amount description A plain text description of medication single dose amount, as described in the AoMRC medication headings, e.g. “30 mg” or “2 tabs”. UK secondary care clinicians and systems normally minimally structure their dose directions, separating dose amount and dose timing (often referred to as dose and frequency). This format is currently used in GP systems, which can import dose and frequency descriptions concatenated into the single dose directions description.

1 1 1 1 1 0 0 0 1 0 1

1 1 1 1 1 0 0 0 1 0 1

1 1 1 1 1 0 0 0 1 0 1

1 1 1 1 1 0 0 0 1 0 1

1 1 1 1 1 1 0 1 1 0 1

0 0 0 0 0 0 0 1 0 0 0

0 0 0 0 0 0 0 1 0 0 0

0 0 0 0 0 0 0 1 0 0 0

0 0 0 0 0 0 0 1 0 0 0

0 0 0 0 0 0 0 1 0 0 0

0 0 0 0 0 0 0 1 0 0 0



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Element Description

Dose directions description A plain text description of the entire prescribed medication dosage and administration directions, including dose quantity and medication frequency.

Dose timing description A plain text description of medication dose frequency, as described in the AoMRC medication headings, e.g. “twice a day”, “at 8am 2pm and 10pm”.UK secondary care clinicians and systems normallyminimally structure their dose directions, separatingdose amount and dose timing (often referred to asdose and frequency). This format is currently usedin GP systems, which can import dose and frequencydescriptions concatenated into the single dosedirections description.

Prescribed quantity Medication quantity prescribed.

Date started This is when the medication was first prescribed.


Valid from date Date the prescription can be issued from, e.g. valid for 6 months.

Number of issues permissible The number of repeat issues permissible.

Number of issues made The number of repeats already issued.

Valid to date Date the prescription is valid to.

Additional instructions Additional multiple dosage or administration instructions as plain text. This may include guidance to the prescriber, patient or person administering the medication. In some settings, specific administration instructions may be re– labelled as “patient advice” or ‘dispensing instruction’ to capture these flavours of instruction, e.g. “omit morning dose on day of procedure”, “for pain or fever”, “dispense weekly”.

Indication Reason for medication was prescribed.


Repeat dispensed This is an indicator as to whether the item will be repeat dispensed by pharmacy.



For medications that have been changed, i.e. additions, amendments and discontinued, in addition to the above, also record:

0 0 0 0 0 0 0 1 0 0 0

0 0 0 0 0 0 0 1 0 0 0

0 0 0 0 0 0 0 1 0 0 0

0 0 0 0 0 0 0 1 0 0 0

0 0 0 0 0 0 0 1 0 0 0

0 0 0 0 0 0 0 1 0 0 0

0 0 0 0 0 0 0 1 0 0 0

0 0 0 0 0 0 0 1 0 0 0

0 0 0 0 0 0 0 1 0 0 0

0 0 0 0 0 0 0 1 0 0 0

0 0 0 0 0 0 0 1 0 0 0

0 0 0 0 0 0 0 1 0 0 0

0 0 0 0 0 0 0 1 0 0 0

0 0 0 0 0 0 0 1 0 0 0

0 0 0 0 0 0 0 1 0 0 0


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Element Description


Indication Reason for change in medication, e.g. sub–therapeutic (for medication change) dose, patient intolerant.








Dose timing description A plain text description of medication dose frequency, as described in the AoMRC medication headings, e.g. “twice a day”, “at 8am, 2pm and 10pm”. UK secondary care clinicians and systems normally minimally structure their dose directions, separating dose amount and dose timing (often referred to as dose and frequency). This format is currently used in GP systems, which can import dose and frequency descriptions concatenated into the single dose directions description.

0 0 0 0 0 0 0 1 0 0 0

0 0 0 0 0 0 0 1 0 0 0

0 0 0 0 0 0 0 1 0 0 0

0 0 0 0 0 0 0 1 0 0 0

0 0 0 0 0 0 0 1 0 0 0

0 0 0 0 0 0 0 1 0 0 0

0 0 0 0 0 0 0 1 0 0 0

0 0 0 0 0 0 0 1 0 0 0

0 0 0 0 0 0 0 1 0 0 0

0 0 0 0 0 0 0 1 0 0 0



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Element Description








Additional instructions Additional multiple dosage or administration instructions as plain text. This may include guidance to the prescriber, patient or person administering the medication. In some settings, specific administration instructions may be re– labelled as “patient advice” or ‘dispensing instruction’ to capture these flavours of instruction, e.g. “omit morning dose on day of procedure”, “for pain or fever”, “dispense weekly”.






Medication name Mandatory medication name coded using SNOMED CT / dm+d term where possible, allowing plain text for historical/patient reported items, extemporaneous preparations or those not registered in dm+d.


0 0 0 0 0 0 0 1 0 0 0

0 0 0 0 0 0 0 1 0 0 0

0 0 0 0 0 0 0 1 0 0 0

0 0 0 0 0 0 0 1 0 0 0

0 0 0 0 0 0 0 1 0 0 0

0 0 0 0 0 0 0 1 0 0 0

0 0 0 0 0 0 0 1 0 0 0

0 0 0 0 0 0 0 1 0 0 0

0 0 0 0 0 0 0 1 0 0 0

0 0 0 0 0 0 0 1 0 0 0

0 0 0 0 0 0 0 1 0 0 0

0 0 0 0 0 0 0 1 0 0 0

0 0 0 0 0 0 0 1 0 0 0

0 0 0 0 0 0 0 1 0 0 0

0 0 0 0 0 0 0 1 0 0 0


Prescribed elsewhere: Medication managed by another organisationPrescribed elsewhere: Medication managed by another organisationPrescribed elsewhere: Medication managed by another organisation

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Element Description






Dose timing description A plain text description of medication dose frequency, as described in the AoMRC medication headings, e.g. “twice a day”, “at 8am 2pm and 10pm”.UK secondary care clinicians and systems normallyminimally structure their dose directions, separatingdose amount and dose timing (often referred to asdose and frequency). This format is currently usedin GP systems, which can import dose and frequencydescriptions concatenated into the single dosedirections description.


Additional instructions Additional multiple dosage or administration instructions as plain text. This may include guidance to the prescriber, patient or person administering the medication. In some settings, specific Administration Instructions may be re- labelled as “patient advice’ or ‘dispensing Instruction’ to capture these flavours of instruction. Comment: e.g. “Omit morning dose on day of procedure”, “for pain or fever”, “dispense weekly”.

0 0 0 0 0 0 0 1 0 0 0

0 0 0 0 0 0 0 1 0 0 0

0 0 0 0 0 0 0 1 0 0 0

0 0 0 0 0 0 0 1 0 0 0

0 0 0 0 0 0 0 1 0 0 0

0 0 0 0 0 0 0 1 0 0 0

0 0 0 0 0 0 0 1 0 0 0

0 0 0 0 0 0 0 1 0 0 0



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Element Description



Organisation Prescribing organisation.

0 0 0 0 0 0 0 1 0 0 0

0 0 0 0 0 0 0 1 0 0 0

0 0 0 0 0 0 0 1 0 0 0


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Admission record

© NHS Digital 2018

Section Two: Admission record

The structure and content for the health and care information to be recorded when a patient is admitted to hospital. Not all structured content

will be used in all care settings or circumstances and the order in which they appear in the digital patient record, communications and letters can

be agreed by system suppliers and users.

GP practice

Element Description


GP practice details Name and address of the patient’s registered GP practice.


Referrer details

Element Description

Referrer details Name, role, grade, organisation and contact details of referrer. If not an individual, this could be with a GP surgery, department, specialty, sub–specialty, educational institution, mental health team etc. Also needs to include self–referral.


Element Description






Sex The person’s phenotypic sex. Determines how the person will be treated clinically.



Patient address Patient’s usual place of residence.

Patient email address Email address of the patient

Patient telephone number Telephone contact details of the patient. To include, e.g. mobile, work and home number if available.

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Element Description

Relevant contacts Include the most important contacts including: • Personal contacts, e.g. next of kin, in case of emergency contact, lasting power of attorney,

dependents, informal carers etc.• Health / care professional contacts e.g. social worker, hospital clinician, care coordinator, key worker,

Independent Mental Capacity Advocate (IMCA) etc. Name, relationship, role (if formal role), contactdetails and availability, e.g. out of hours.

Communication preferences Preferred contact method, e.g. sign language, letter, phone, etc. Also preferred written communication format, e.g. large print, braille.

Social context

Element Description

Household composition E.g. lives alone, lives with family, lives with partner, etc. This may be free text.





Social circumstances The record of a patient’s social background, network and personal circumstances, e.g. housing, religious, ethnic and spiritual needs, social concerns and whether the patient has dependents or is a carer. May include reference to safeguarding issues that are recorded elsewhere in the record.

Services and care The description of services and care providing support for patient’s health and social well-being.


Element Description



Element Description


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Admission details

Element Description

Reason for admission The health problems and issues experienced by the patient that prompted the decision to admit to hospital, e.g. chest pain, mental health crisis, blackout, fall, a specific procedure, intervention, investigation or treatment, non compliance with treatment.

Admission method How the patient was admitted to hospital. For example: elective, emergency, maternity, transfer etc.

Source of admission Where the patient was immediately prior to admission, e.g. usual place of residence, temporary place of residence, penal establishment. National code.

Date / time of admission Date and time patient admitted to hospital.

Patient location This is the physical locations of the patient. For inpatient, e.g. hospital ward, bed, theatre. For ambulatory care, e.g. health centre, clinic, resources centre, patient’s home.


Person accompanying patient Identify others accompanying the patient, e.g. relative, friend, informed carer, advocate. If the patient was not present was an authorised representative present? Includes name relationship (spouse, etc) role (patient advocate, etc.).

Speciality Specialties designated by royal college and faculties, e.g. orthopaedics, renal medicine and endocrinology, etc.

Discharge details

Element Description



Element Description

Relevant clinical risk factor Factors that have been shown to be associated with the development of a medical condition being considered as a diagnosis / differential diagnosis, e.g. being overweight, smoker, no use of sun screen, enzyme deficiency.



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Problems and issues

Element Description


History

Element Description

Presenting complaints or issues The list and description of the health problems and issues experienced by the patient resulting in the attendance. This may include disease state, medical condition, response and reaction to therapies, e.g. blackout, dizziness, chest pain, follow–up from admission, falls, a specific procedure, investigationor treatment.

History of each presenting Information directly related to the development and characteristics of each presenting complaint (e.g. complaint or issue including travel history). Including if the information is given by the patient or their carer.

Relevant past medical, surgical The record of the person’s significant medical, surgical and mental health history. Including relevant and mental health history previous diagnoses, problems and issues, procedures, investigations, specific anaesthesia issues, etc

(will include dental and obstetric history).

Reason for admission The health problems and issues experienced by the patient resulting in their referral by a healthcare professional for hospital admission, e.g. chest pains blackouts, falls, a specific procedure, investigation or treatment.

Information brought by patient E.g. patient passport, example diary data, pre–completed questionnaires, person–held maternity record,personal child health record, etc.

Clinical summary

Element Description

Clinical summary Summary of the 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’.

Family history

Element Description


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Admission record

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Assessment scales

Element Description


Legal information

Element Description



Safety alerts

Element Description

Risks to self Risks the patient poses to themselves, e.g. suicide, overdose, self–harm, self–neglect.


Risk from others Details of where an adult or child is at risk from an identified person, e.g. family member etc.


Element Description




Element Description

Investigation result For each investigation, the result of the investigation (this includes the result value, with unit of observation and reference interval where applicable and date), and plans for acting upon investigation results.


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Element Description

Patient concerns, Description of the concerns, wishes or goals of the person in relation to their care, as expressed expectations and wishes by the person, their representative or carer. Record who has expressed these (patient or carer /

representative on behalf of the patient). Where the person lacks capacity this may include their representative’s concerns, expectations or wishes.


Element Description


Clinical review of systems

Element Description

Clinical review of systems The clinical review of systems. The record of clinical information gathered in responses to questions to the patient about specific symptoms from various physiological systems, including food intake (increasing / decreasing) weight change, swallowing difficulties etc.


Element Description

Information and advice given This includes: • what information• to whom it was given.• the oral or written information or advice given to the patient, carer, other authorised representative,

care professional or other third party. May include advice about actions related to medicines orother ongoing care activities on an ‘information prescription’. State here if there are concernsabout the extent to which the patient and / or carer understand the information provided aboutdiagnosis, prognosis and treatment.

Element Description

Date first experienced When the reaction was first experienced. May be a date or partial date (e.g. year) or text (e.g. during childhood).


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Element Description






Element Description










Element Description

Actions for patient or their carer For each action the following should be identified a) person responsible – name and designation, e.g. patient or carer responsible for carrying out the

proposed action, and where action should take place.b) status – requested, planned or completed.c) When action requested for – requested date, time, or period – as relevant.d) suggested strategies – suggested strategies for potential problems, e.g. telephone contact for advice.e) outcome expectations, including patient’s expectations.

Agreed with patient or Indicates whether the patient or legitimate representative has agreed the entire plan or individual legitimate patient aspects of treatment, expected outcomes, risks and alternative treatments. representative

Special monitoring required E.g. neuro–obs, 02 saturation etc.


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Element Description

Dose directions description A single plain text phrase describing the entire medication dosage and administration directions including dose quantity and medication frequency. Comment, e.g. “1 tablet at night or “2mg at 10pm”. This is the form of dosage direction text normally available from UK GP systems.

Additional instructions Allows for: • requirements for adherence support, e.g. compliance aids, prompts and packaging requirements • additional information about specific medicines, e.g. where specific brand required • person requirements, e.g. unable to swallow tablets.




For medications that have been changed, i.e. additions, amendments and discontinued, in addition to the above, also record:

Description of amendment Where a change is made to the medication i.e. one drug stopped and another started or, e.g. dose, frequency or route is changed.

Indication Reason for change in medication, e.g. sub–therapeutic dose, patient intolerant. (for medication change)



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Handover record

© NHS Digital 2018

Section Three: Handover record

The structure and content for the health and care information to be recorded and used when a patient is handed over from one professional

team to another within a hospital setting.

Not all structured content will be used in all care settings or circumstances and the order in which they appear in the digital patient record,


GP practice

Element Description





Element Description










Patient email address Email address of the patient.


Relevant contacts Include the most important contacts including: • Personal contacts, e.g. next of kin, in case of emergency contact, lasting power of attorney, dependents, informal carers etc. • Health / care professional contacts, e.g. social worker, hospital clinician, care coordinator, key worker, Independent Mental Capacity Advocate (IMCA) etc. Name, relationship, role (if formal role), contact details and availability, e.g. out of hours.


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Social context

Element Description



Element Description



Element Description


Admission details

Element Description



Patient location This is the physical locations of the patient. For inpatient, e.g. hospital ward, bed, theatre. For ambulatory care, e.g. health centre, clinic, resources centre, patient’s home.


Discharge details

Element Description


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Element Description




Patient at high risk This patient is at high risk of clinical deterioration and will need an immediate response if called.

Problems and issues

Element Description


Diagnoses

Element Description

Diagnosis Confirmed diagnosis (or symptom); active diagnosis being treated.

History

Element Description

Relevant past medical, surgical The record of the person’s significant medical, surgical and mental health history. Including relevant and mental health history previous diagnoses, problems and issues, procedures, investigations, specific anaesthesia issues, etc (will include dental and obstetric history).

Clinical summary

Element Description


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Element Description

Investigation result For each investigation, the result of the investigation (this includes the result value, with unit of observation and reference interval where applicable and date, and plans for acting upon investigation results.

Legal information

Element Description




Element Description






Element Description

Patient concerns, Description of the concerns, wishes or goals of the person in relation to their care, as expressed expectations and wishes by the person, their representative or carer. Record who has expressed these (patient or carer / representative on behalf of the patient). Where the person lacks capacity this may include their representative’s concerns, expectations or wishes.

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Handover record

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Element Description

Information and advice given This includes: • what information • to whom it was given. • the oral or written information or advice given to the patient, carer, other authorised representative, care professional or other third party. May include advice about actions related to medicines or other ongoing care activities on an ‘information prescription’. State here if there are concerns about the extent to which the patient and / or carer understand the information provided about diagnosis, prognosis and treatment”.


Element Description

Actions for patient or their carer For each action the following should be identified a) person responsible – name and designation, e.g. patient or carer responsible for carrying out the proposed action, and where action should take place. b) status – requested, planned or completed. c) When action requested for – requested date, time, or period – as relevant. d) suggested strategies – suggested strategies for potential problems, e.g. telephone contact for advice. e) outcome expectations, including patient’s expectations.

Agreed with patient or Indicates whether the patient or legitimate representative has agreed the entire plan or individual legitimate patient aspects of treatment, expected outcomes, risks and alternative treatments. representative

Aims and limitations of The current aim of treatment including limitations to treatment and communications issues, e.g., treatment and special not for ITU. instructions

Escalation plan Who needs to be contacted in the event of significant problems or patient deterioration include, e.g. seniority / name / contact details of person to be called.

Outstanding issues

Element Description

Tasks which must be done Include timescales (appropriate seniority of staff for each task).

Tasks to be done if possible E.g. test review, pre–discharge documents, criteria for discharge, including who may discharge the patient.

Person handing over

Element Description



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Person receiving handover

Element Description

Name The name of the person receiving the handover, preferably in a structured format.

Role The role the person is playing within the organisation at the time of handover.

Grade The grade of the person receiving the handover.

Specialty The speciality of the person receiving the handover.

Contact details Contact details of the person receiving the handover. For example a phone number, email address. Contact details are used to resolve queries about the record entry.

Handover details

Element Description

Patient Location This is the physical location of the patient. For inpatient, e.g. hospital ward, bed, theatre. For ambulatory care, e.g. health centre, clinic, resources centre, patient’s home.

Planned patient location If patient is changing location.

Date of admission Date patient admitted to hospital.



Specialty Specialities designated by royal colleges and faculties. E.g. orthopaedics, renal medicine, endocrinology, etc.

Service Subspecialties, treatment functions or services. E.g. hand surgery, back surgery, hand clinic, TIA clinic, falls clinic, speech and language therapy, dialysis, family therapy, pre–admission assessment clinic etc.

Element Description





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Handover record

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Element Description

Date of decision to handover Date decision made to handover care.

New responsible consultant The name and designation of the consultant who is accepting responsibility for the patient’s inpatient care.

Date handover accepted Date decision made to accept handover of care.

Reason for handover A clear statement of the reason for the temporary or permanent handover of care, e.g. low potassium, immediately post–op, unstable medical condition.

Senior clinical contact team If there is a particular requirement to call a specific person, e.g. consultant, SpR or special intervention.

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Section Four: Discharge record

The structure and content for the health and care information to be recorded in all discharge records and discharge summary communications

sent from hospital services (including acute care discharge, mental health discharge and emergency care discharge) to GPs.



GP practice

Element Description




1 1 1

1 1 1

1 1 1

D M E

Referrer details

Element Description

Referrer details Name, role, grade, organisation and contact details of referrer. If not an individual, this could be a GP surgery, department, specialty, sub–specialty, educational institution, mental health team etc. Also needs to include self–referral.

1 1 1

D M E


Element Description










1 1 1

1 1 0

1 1 1

1 1 1

1 1 1

1 1 1

1 1 1

1 1 1

1 1 1

D M E

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Element Description

Relevant contacts Include the most important contacts including: • Personal contacts, e.g. next of kin, in case of emergency contact, lasting power of

attorney, dependents, informal carers etc.• Health / care professional contacts e.g. social worker, hospital clinician, care

coordinator, key worker, Independent Mental Capacity Advocate (IMCA) etc.Name, relationship, role (if formal role), contact details and availability, e.g.out of hours.


Educational establishment If the patient is a child, name and address of where the child attends, e.g. play group, nursery, school.

1 1 0

1 0 0

0 0 1

D M E

Social context

Element Description






1 1 0

1 1 0

1 1 0

0 1 0

0 1 0

D M E


Element Description


1 1 0

D M E


Element Description

Name of research study Name of the research study / trial and / or drug / intervention. 1 1 0

D M E

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Attendance details

Element Description

Date and time of contact Date and time of the appointment, contact or attendance. 0 0 1

D M E

Admission details

Element Description


Admission method How the patient was admitted to hospital. For example: elective, emergency, maternity, transfer etc.

Legal Status on admission Record if the patient was admitted as Informal or formal / detained.



1 1 0

1 1 0

0 1 0

1 1 0

1 1 0

D M E

Discharge details

Element Description

Discharge destination The destination of the patient on discharge. National codes, e.g. high dependency unit.


Discharging consultant The consultant responsible for the patient at time of discharge.

Discharging specialty The specialty or department responsible for the patient at the time of discharge. / department


Date / time of discharge The actual date of discharge.

Legal Status on discharge Record if the patient was discharged as Informal or formal / detained.

Discharge method The method of discharge from hospital. National codes, e.g. patient discharged on clinical advice or with clinical consent; patient discharged him / herself or was discharged by a relative or advocate; patient died; stillbirth.

0 0 1

0 0 1

1 1 0

1 1 0

1 1 0

1 1 1

0 1 0

1 1 0

D M E

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Discharge record

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Element Description

Discharge destination comprising:

Discharge type The destination of the patient on discharge from hospital. National codes, e.g. NHS–run care home.

Discharge address Address to which patient discharged. Only complete where this is not the usual place of residence.

1 1 0

1 1 0

1 1 0

D M E

Presenting complaints or issues

Element Description

Presenting complaint or issue The health problem or issue experienced by the patient resulting in their attendance. This may include disease state, medical condition, response and reactions to therapies, e.g. blackout, dizziness, chest pain, follow up from admission, falls, a specific procedure, investigation or treatment.

0 0 1

D M E

Diagnoses

Element Description


Stage Stage of the disease or disorder, where relevant.


1 1 1

1 1 0

1 1 1

D M E

History

Element Description

Presenting complaints or issues The list and description of the health problems and issues experienced by the patient resulting in the attendance. This may include disease state, medical condition, response and reaction to therapies, e.g. blackout, dizziness, chest pain, follow–up from admission, falls, a specific procedure, investigation or treatment.

0 0 1

D M E

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Procedures

Element Description



Laterality Laterality of the procedure.

Complications related Details of any intra–operative complications encountered during the procedure, to procedure arising during the patient’s stay in the recovery unit or directly attributable to

the procedure.

Specific anaesthesia issues Details of any adverse reaction to any anaesthetic agents including local anaesthesia. Problematic intubation, transfusion reaction, etc.

Comment Any further textual comment to clarify such as statement that information is partial or incomplete.

1 1 1

1 1 1

1 1 1

1 1 1

1 1 1

1 1 1

D M E

Clinical summary

Element Description


Formulation An account, shared by a therapist and person, of the personal meaning and origins of a person’s difficulties. This is viewed in the context of multiple factors including relationships, social circumstances and life events and will indicate the most helpful way forward.

Treatments and interventions The relevant treatments and interventions which the patient received during the and changes made to inpatient stay. Include psychological therapies. All medications should be recorded treatments. under the medications section.


1 1 1

0 1 0

0 1 0

0 0 1

D M E

Family history

Element Description


0 1 0

D M E

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Element Description

Investigation result For each investigation, the result of the investigation (this includes the result value, with unit of observation and reference interval where applicable and date), and plans for acting upon investigation results.

0 1 0

D M E

Assessment scales

Element Description


0 1 0

D M E

Legal information

Element Description

Mental Health Act Record where a person diagnosed with a mental disorder is formally detained or equivalent status under the Mental Health Act or equivalent, including the section number and

start date, start time and end date. If person subject to community treatment order or conditional discharge (or equivalent) record here.

Advance decision to A record of an advance decision to refuse one or more specific types of future refuse treatment (ADRT) 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.






0 1 0

1 1 0

1 1 0

1 1 0

1 1 0

1 1 0

1 0 0

D M E


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Safety alerts

Element Description



Risk from others Details of where an adult or child is at risk from an identified person, e.g. family member etc.

1 1 1

1 1 1

1 1 1

D M E


Element Description




1 1 1

1 1 1

1 1 1

D M E

Safeguarding

Element Description

Safeguarding concerns A record of any identification of concerns regarding safeguarding during attendance.

Comment A comment providing further detail on a safeguarding concern.

0 0 1

0 0 1

D M E

Element Description


Lasting power of attorney Record of one or more people who have been given power (LPA) by the person for personal welfare or when they had capacity to make decisions about their health and welfare should court-appointed deputy they lose capacity to make those decisions. To be valid, an LPA must have been (or equivalent) registered with the Court of Protection. If life-sustaining treatment is being

considered the LPA document must state specifically that the attorney has been given power to consent to or refuse life-sustaining treatment. Details of any person (deputy) appointed by the court to make decisions about the person’s health and welfare. A deputy does not have the power to refuse life-sustaining treatment.

1 1 0

1 1 0

D M E

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Element Description

Patient concerns, Description of the concerns, wishes or goals of the person in relation to their expectations and wishes care, as expressed by the person, their representative or carer. Record who has

expressed these (patient or carer / representative on behalf of the patient). Where the person lacks capacity this may include their representative’s concerns, expectations or wishes.

1 1 0

D M E

Element Description









1 1 0

1 1 1

1 1 0

1 1 0

1 1 0

1 1 1

1 1 0

1 1 0

D M E


Element Description

Information and advice given This includes: • what information• to whom it was given.• the oral or written information or advice given to the patient, carer, other

authorised representative, care professional or other third party. May includeadvice about actions related to medicines or other ongoing care activities onan ‘information prescription’. State here if there are concerns about the extentto which the patient and / or carer understand the information provided aboutdiagnosis, prognosis and treatment.

1 1 1

D M E

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Element Description









1 1 1

1 1 0

1 1 0

1 1 0

1 1 1

1 1 0

1 1 0

1 1 0

D M E


Element Description

Actions for patient or their carer For each action the following should be identified a) person responsible – name and designation, e.g. patient or carer responsible

for carrying out the proposed action, and where action should take place.b) status – requested, planned or completed.c) When action requested for – requested date, time, or period – as relevant.d) suggested strategies – suggested strategies for potential problems, e.g.

telephone contact for advice.e) outcome expectations, including patient’s expectations.

Actions for healthcare Including planned investigations, procedures and treatment for a patient’s professionals identified conditions and priorities. For each action the following should be

identified: outcome expectations, including patient’s expectations

Agreed with patient or Indicates whether the patient or legitimate representative has agreed the legitimate patient entire plan or individual aspects of treatment, expected outcomes, risks and representative alternative treatments.


Investigations requested This includes a name or description of the investigation requested and the date requested.

Procedures requested These are the diagnostic or therapeutic procedures that have actually been requested (and the date requested).

1 1 1

1 1 0

1 1 0

0 1 0

1 1 0

1 1 0

D M E

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Discharge record

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Senior reviewing clinician

Element Description

Name The name of the senior clinician responsible for reviewing the patient treatment and discharge plan.

Professional identifier The unique identifier issued by the regulatory body, e.g. GMC number, HCPC number etc.

0 0 1

0 1 1

D M E

Contact for further information

Element Description

Contact for further The contact details of whom to contact for information regarding this attendance. information

0 0 1

D M E

Distribution list

Element Description

Name If the communication is being sent to a named individual, then this is the name of the recipient, preferably in a structured format. An identifier for the individual, for example GMC code (for a GP), or an SDS identifier, a NHS number (for a patient) will be sent alongside the name, but may not displayed on rendered document.






1 1 0

1 1 0

1 1 0

1 1 0

1 1 0

1 1 0

D M E

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Element Description








Dose timing description A description of the frequency of taking or administration of a medication dose. E.g. “twice a day”, “at 8am 2pm and 10pm”.

Dose directions description A single plain text phrase describing the entire medication dosage and administration directions including dose quantity and medication frequency, e.g. “1 tablet at night or “2mg at 10pm”. This is the form of dosage directiontext normally available from UK GP systems.

Parsable dose directions A parsable ‘dose syntax’ which carries dose strength, dose timing, dose duration and maximum dose information, e.g. “20-30mg ^4 / 6h prn [180mg / 24h]” = 20 to 30 mgs, up to 4-6 hourly as required. Maximum 180mg in 24 hours. The ‘as required reason’ e.g. ‘for pain’ should be carried in the Additional Instruction element. Note that this is generally a symptom and is not the same as the Indication which will usually describe a diagnosis or condition. Where supported, this would generally be used to exchange dosage information between systems, while Structured dose directions are likely to be used only within open EHR-based systems.

Structured dose A structural representation of the elements carried by the dose syntax in direction cluster ‘Parsable dose Strength / timing’ i.e. dose strength, dose timing, dose duration

and maximum dose.

Structured dose amount cluster A structural representation of dose amount, e.g. 20mg or 2 tablets This element will generally only be used when persisting data within systems with ‘Parsable dose directions’ being used to exchange the same information between systems.

Structured dose timing cluster A slot containing a structural, computable representation of dose timing and maximum dose, This element will generally only be used when persisting data within systems with ‘Parsable dose directions’ being used to exchange the same information between systems.

Additional instructions Allows for: • requirements for adherence support, e.g. compliance aids, prompts and

packaging requirements• additional information about specific medicines, e.g. where specific brand required• person requirements, e.g. unable to swallow tablets.


1 1 1

1 1 1

1 1 1

1 1 1

1 1 1

1 1 1

1 1 1

1 1 1

1 1 1

1 1 1

1 1 1

1 1 1

1 1 1

1 1 1

1 1 1

D M E

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Element Description













Date of latest change The date of the latest change – addition or amendment.



Total dose daily quantity cluster The total daily dose of this medication. This is helpful for estimating optimal adherence to dosing guidance. It may be computed from product/dose strength and frequency or entered manually.


Medical devices entry


1 1 1

1 1 1

1 1 1

1 1 1

1 1 1

1 1 1

1 1 1

1 1 1

1 1 1

1 1 1

1 1 1

1 1 1

1 1 1

1 1 1

1 1 1

1 1 1

D M E


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Element Description


Name of discontinued The name of the medication or medical device being discontinued. medication






1 1 1

1 1 1

1 1 1

1 1 1

1 1 1

1 1 1

1 1 1

D M E

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Outpatient letter

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Section Five: Outpatient Letter

The structure and content for the health and care information to be recorded in all outpatient letters sent from hospital to GP.



GP practice

Element Description




Referrer details

Element Description

Referrer details Name, role, grade, organisation and contact details of referrer. If not an individual, this could be e.g. GP surgery, department, specialty, sub–specialty, educational institution, mental health team etc. Also needs to include self–referral.


Element Description











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Element Description

Relevant contacts Include the most important contacts including: • Personal contacts, e.g. next of kin, in case of emergency contact, lasting power of attorney, dependents, informal carers etc. • Health / care professional contacts e.g. social worker, hospital clinician, care coordinator, key worker, Independent Mental Capacity Advocate (IMCA) etc. name, relationship, role (if formal role), contact details and availability, e.g. out of hours.


Social context

Element Description








Social circumstances The record of a patient’s social background, network and personal circumstances, e.g. housing, religious, ethnic and spiritual needs, social concerns and whether the patient has dependents or is a carer. May include reference to safeguarding issues that are recorded elsewhere in the record.



Element Description



Element Description


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Outpatient letter

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Attendance details

Element Description

Date and time of contact Date and time of the appointment, contact or attendance.

Contact type First contact, follow–up contact.

Consultation method Consultation method used identifies the communication mechanism used to relay information between the care professional and the person who is the subject of the consultation, during the outpatient encounter.

Responsible healthcare The name and designation of the consultant, nurse consultant, midwife, allied health professional professional who has overall responsibility for the patient (may not actually see the patient).

Specialty Specialties designated by royal colleges and faculties, e.g. orthopaedics, renal medicine, endocrinology, etc.

Service Treatment functions or services, e.g. hand surgery, back surgery, hand clinic, TIA clinic, falls clinic, speech and language therapy, dialysis, family therapy, pre–admission assessment clinic, etc.

Seen by Doctor, nurse or other healthcare professional that sees the patient. Record the most senior member of staff present. Includes name, role, telephone number.

Care professionals present The name, designation of the additional individuals or team members including consultant(s), nurse consultant(s), allied health professional(s), social worker(s).

Person accompanying patient Identify, where clinically relevant, others accompanying the patient, e.g. relative, friend, informal carer, advocate. If the patient was not present, was an authorised representative present? Includes: name, relationship, role (patient advocate).

Outcome of outpatient This records the outcome of an outpatient attendance. attendance


Element Description




Problems and issues

Element Description


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Diagnoses

Element Description




History

Element Description

Patient’s reason for referral Patient stated reason for referral. This may include any discussions that took place, the level of shared decision making involved, information about patient’s source of advice. This may be expressed on behalf of the patient, e.g. by parent or carer.

Presenting complaints or issues The list and description of the health problems and issues experienced by the patient resulting in the attendance. This may include disease state, medical condition, response and reaction to therapies, e.g. blackout, dizziness, chest pain, follow–up from admission, falls, a specific procedure, investigation or treatment.

History of each presenting Information directly related to the development and characteristics of each presenting complaint (e.g. complaint or issue including travel history). Including if the information is given by the patient or their carer.

History since last contact History since last attendance, discharge from hospital, etc.

Relevant past medical, The record of the person’s significant medical, surgical and mental health history. Including relevant surgical and mental previous diagnoses, problems and issues, procedures, investigations, specific anaesthesia issues, etc health history (will include dental and obstetric history).

Procedures

Element Description




Complications related Details of any intra–operative complications encountered during the procedure, arising during to procedure the patient’s stay in the recovery unit or directly attributable to the procedure.


Comment Any further textual comment to clarify such as statement that information is partial or incomplete.

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Outpatient letter

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Clinical summary

Element Description


Family history

Element Description



Element Description



Assessment scales

Element Description


Legal information

Element Description

Mental Health Act Record where a person diagnosed with a mental disorder is formally detained under the Mental or equivalent status Health Act or equivalent, including the section number and start date, start time and end date. If

person subject to community treatment order or conditional discharge (or equivalent) record here.


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Element Description

Advance decision to A record of an advance decision to refuse one or more specific types of future treatment, made by refuse treatment (ADRT) 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.


Safety alerts

Element Description

Risks to self Risks the patient poses to themselves, e.g. suicide, overdose, self-harm, self-neglect.


Risk from others Details of where an adult or child is at risk from an identified person e.g. family member etc.


Element Description









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Outpatient letter

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Element Description

Information and advice given This includes: • what information • to whom it was given. • the oral or written information or advice given to the patient, carer, other authorised representative, care professional or other third party. May include advice about actions related to medicines or other ongoing care activities on an ‘information prescription’. State here if there are concerns about the extent to which the patient and / or carer understand the information provided about diagnosis, prognosis and treatment.


Element Description

Patient concerns, Description of the concerns, wishes or goals of the person in relation to their care, as expressed expectations and wishes by the person, their representative or carer. Record who has expressed these (patient or carer / representative on behalf of the patient). Where the person lacks capacity this may include their representative’s concerns, expectations or wishes.



Element Description



Clinical review of systems

Element Description

Clinical review of systems The record of clinical information gathered in responses to questions to the patient about specific symptoms from various physiological systems, including food intake (increasing / decreasing) weight change, swallowing difficulties etc.

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Element Description

Actions for patient or their carer For each action the following should be identified a) person responsible – name and designation, e.g. patient or carer responsible for carrying out the

proposed action, and where action should take place.b) status – requested, planned or completed.c) When action requested for – requested date, time, or period – as relevant.d) suggested strategies – suggested strategies for potential problems, e.g. telephone contact

for advice.e) outcome expectations, including patient’s expectations.

Actions for healthcare Including planned investigations, procedures and treatment for a patient’s identified conditions and professionals priorities. For each action the following should be identified: outcome expectations, including

patient’s expectations.

Agreed with patient or Indicates whether the patient or legitimate representative has agreed the legitimate patient entire plan or individual aspects of treatment, expected outcomes, risks and representative alternative treatments.



Element Description








Distribution list

Element Description

Name If the communication is being sent to a named individual, then this is the name of the recipient, preferably in a structured format. An identifier for the individual, for example GMC code (for a GP), or an SDS identifier, a NHS Number (for a patient) will be sent alongside the name, but may not displayed on rendered document.

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Element Description










Parsable dose directions A parsable ‘dose syntax’ which carries dose strength, dose timing, dose duration and maximum dose information, e.g. “20-30mg ^4 / 6h prn [180mg / 24h]” = 20 to 30 mgs, up to 4-6 hourly as required. Maximum 180mg in 24 hours. The ‘as required reason’ e.g. ‘for pain’ should be carried in the Additional Instruction element. Note that this is generally a symptom and is not the same as the Indication which will usually describe a diagnosis or condition. Where supported, this would generally be used to exchange dosage information between systems, while Structured dose directions are likely to be used only within openEHR-based systems.

Structured dose A structural representation of the elements carried by the dose syntax in ‘Parsable dose Strength / direction cluster timing’ i.e. dose strength, dose timing, dose duration and maximum dose.

Element Description







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Element Description

Structured dose amount cluster A structural representation of dose amount, e.g. 20mg or 2 tablets This element will generally only be used when persisting data within systems with ‘Parsable dose directions’ being used to exchange the same information between systems.

Structured dose timing cluster A slot containing a structural, computable representation of dose timing and maximum dose. Comment: This element will generally only be used when persisting data within systems with ‘Parsable dose directions’ being used to exchange the same information between systems.

Additional instructions Allows for: • requirements for adherence support, e.g. compliance aids, prompts and packaging requirements• additional information about specific medicines e.g. where specific brand required• person requirements, e.g. unable to swallow tablets.





Course status The status of this prescription in an ambulatory (out patient / GP / community) context














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Outpatient letter

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Element Description










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Section Six: Crisis care plan

The structure and content for the health and care information to be recorded in crisis care plans in any health or social care setting.



GP practice

Element Description





Element Description














Relevant contacts Include the most important contacts including: • Personal contacts e.g. next of kin, in case of emergency contact, lasting power of attorney,

dependents, informal carers etc.• Health / care professional contacts e.g. social worker, hospital clinician, care coordinator, key worker,

Independent Mental Capacity Advocate (IMCA) etc. Name, relationship, role (if formal role), contactdetails and availability, e.g. out of hours.

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Crisis care plan

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Social context

Element Description



Access Special access requirements e.g. key safe, coded lock, which door to use, stretcher access, etc.

Dependents Provide details of any responsibility the person has for dependents. In the case of minors provide additional details e.g. date of birth etc.


Element Description


Problems and issues

Element Description


Clinical risks Description of clinical risks identified e.g. problematic intubation, person with brittle diabetes, immuno–compromised / risk of infection etc.

Diagnoses

Element Description


Awareness of diagnosis Description of the level of awareness the person and or their carer / family has regarding their diagnosis.

History

Element Description

Relevant past medical, The record of the person’s significant medical, surgical and mental health history. Including relevant surgical and mental previous diagnoses, problems and issues, procedures, investigations, specific anaesthesia issues, etc health history (will include dental and obstetric history).

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Legal information

Element Description

Mental Health Act Record where a person diagnosed with a mental disorder is formally detained under the Mental or equivalent status Health Act or equivalent, including the section number and start date, start time and end date. If

person subject to community treatment order or conditional discharge (or equivalent) record here.

Advance decision to A record of an advance decision to refuse one or more specific types of future treatment, made by refuse treatment (ADRT) 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.



Consent for creation of Separate explicit consent is required for creation of an end of life care record. This records how this end of life care plan consent has been granted in order to differentiate between person’s explicit consent, best interest

decision, lasting power of attorney decision and withdrawal of consent.


Parental responsibility For children this is a record of person(s) with parental responsibility.

Deprivation of liberty Record of Deprivation of Liberty Safeguards (DoLS) or equivalent, including the reason for this. safeguards or equivalent

Lasting power of attorney for Record of one or more people who have been given power (LPA) by the person when they had personal welfare or capacity to make decisions about their health and welfare should they lose capacity to make those court-appointed deputy decisions. To be valid, an LPA must have been registered with the Court of Protection. If life-sustaining (or equivalent) treatment is being considered the LPA document must state specifically that the attorney has been

given power to consent to or refuse life-sustaining treatment. Details of any person (deputy) appointed by the court to make decisions about the person’s health and welfare. A deputy does not have the power to refuse life-sustaining treatment.

Safety Alerts

Element Description




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Crisis care plan

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Crisis care plan

Element Description

Care funding details A record of the funding source and any conditions or limitations associated.

Priorities of care 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.

Estimated prognosis Where a person is terminally ill this is a clinical judgment indicating the anticipated period of time until death, e.g. last days, weeks, months or year of life. Also include the date the prognosis was made.

Awareness of prognosis Description of the level of awareness the person and or their carer / family has regarding their estimated prognosis.

Anticipatory actions Please provide guidance on specific interventions or actions that may be required or should be avoided in specific situations.

Anticipatory Medicines or equipment available in the event of a crisis and their location. medicines / equipment


Element Description

Patient concerns, Description of the concerns, wishes or goals of the person in relation to their care, as expressed by expectations and wishes the person, their representative or carer. Record who has expressed these (patient or carer /

representative on behalf of the patient). Where the person lacks capacity this may include their representative’s concerns, expectations or wishes.


Preferred place of care The preferences that a person has identified as their preferred place to receive care.

Preferred place of death The preferences that a person has identified as their preferred place to die.


Element Description




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End of life

Element Description

Certification of death If person is in their last weeks of life, is there a doctor who has seen the person recently who could potentially sign a death certificate? Provide contact details.

Actions taken in Plan that has been agreed to facilitate certification of death and / or funeral arrangements, e.g. anticipation of death anticipatory discussions with coroner to arrange funeral within 24 hours etc.

Actual place of death The location where the person actually died as recorded on the death certificate. If the person died somewhere other than their preferred place, record the reasons why this happened.

Cause of death The cause of death as recorded on the death certificate.

Date of death The date on which a person died or is officially deemed to have died, as recorded on the death certificate.


Element Description



Professional identifier Professional identifier for the person completing the record, e.g. GMC number, HCPC number etc or the personal identifier used by the local organisation.




Element Description

Agreed with person or Indicates whether the crisis care plan was discussed and agreed with the person or legitimate legitimate representative representative. If agreement cannot be obtained the reason for this should be documented.

Cardio–pulmonary Whether a decision has been made, the decision, who made the decision, the date of decision, date resuscitation (CPR) decision 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.

Planned review date Date the plan is due for review.

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Element Description







Dose amount description A description of the medication single dose amount e.g. “30 mg” or “2 tabs”.


Dose directions description A single plain text phrase describing the entire medication dosage and administration directions including dose quantity and medication frequency, e.g. “1 tablet at night” or “2mg at 10pm”. This is the form of dosage direction text normally available from UK GP systems.



Structured dose A structural representation of dose amount, e.g. 20mg or 2 tablets This element will generally only amount cluster be used when persisting data within systems with ‘Parsable dose directions’ being used to exchange

the same information between systems.

Structured dose A slot containing a structural, computable representation of dose timing and maximum dose. timing cluster Comment: This element will generally only be used when persisting data within systems with

‘Parsable dose directions’ being used to exchange the same information between systems.

Allows for: Additional instructions • requirements for adherence support, e.g. compliance aids, prompts and packaging• additional information about specific medicines e.g. where specific brand required• person requirements, e.g. “unable to swallow tablets”.





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Element Description


Course status The status of this prescription in an ambulatory (out patient / GP / community) context























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Clinical referral information

© NHS Digital 2018

Section Seven: Clinical referral information

The structure and content for the health and care information to be recorded in all clinical referral information sent from GPs to secondary

care consultants.



GP practice

Element Description




1

1

1

R

Referrer details

Element Description

Referrer details Name, role, grade, organisation and contact details of referrer. If not an individual, this could be, e.g. GP surgery, department, specialty, sub–specialty, educational institution, mental health team etc. Also needs to include self–referral.

Attachments Documents included as attachments which accompany the communication Data items: • number of attachments• type of attachments• attached documents.

Details of other referrals Other referrals related to this or associated conditions.

Referral criteria Records whether specific criteria required for referral, to a particular service, have been met (may be nationally or locally determined).

Return response to Name of care professional to be communicated with by the hospital, if not the referrer.

1

1

1

1

1

R


Element Description






1

1

1

1

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Element Description





Relevant contacts Include the most important contacts including: • Personal contacts, e.g. next of kin, in case of emergency contact, lasting power

of attorney, dependents, informal carers etc.• Health / care professional contacts e.g. social worker, hospital clinician, care

coordinator, key worker, independent mental capacity advocate (IMCA) etc.Name, relationship, role (if formal role), contact details and availability, e.g. out of hours.


Educational establishment If the patient is a child, name and address of where the child attends, e.g. play group, nursery, school.

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Social context

Element Description






Social circumstances The record of a patient’s social background, network and personal circumstances, e.g. housing, religious, ethnic and spiritual needs, social concerns and whether thepatient has dependents or is a carer. May include reference to safeguarding issuesthat are recorded elsewhere in the record.

Services and care The description of services and care providing support for patient’s health and social wellbeing.

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Element Description

Name of research study Name of the research study / trial and / or drug / intervention. 1

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Family history

Element Description


Maternal or paternal relation Record of whether the condition or diagnosis was on the mother’s or father’s side of the family, where needed, e.g. paternal grandfather.



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Assessment scales

Element Description


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Legal information

Element Description

Advance decision to A record of an advance decision to refuse one or more specific types of future refuse treatment (ADRT) 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.







Lasting power of attorney for Record of one or more people who have been given power (LPA) by the person personal welfare or when they had capacity to make decisions about their health and welfare should they court-appointed deputy lose capacity to make those decisions. To be valid, an LPA must have been registered (or equivalent) with the Court of Protection. If life-sustaining treatment is being considered the LPA

document must state specifically that the attorney has been given power to consent to or refuse life-sustaining treatment. Details of any person (deputy) appointed by the court to make decisions about the person’s health and welfare. A deputy does not have the power to refuse life-sustaining treatment.

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Safety alerts

Element Description




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Causative agent The agent such as food, drug or substances that has caused or may cause an allergy, intolerance or adverse reaction in this patient. Or “no known drug allergies or adverse reactions” or “information not available.




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Patient concerns, Description of the concerns, wishes or goals of the person in relation to their care, expectations and wishes as expressed by the person, their representative or carer. Record who has expressed

these (patient or carer/representative on behalf of the patient). Where the person lacks capacity this may include their representative’s concerns, expectations or wishes.

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Element Description

Information and advice given This includes: • what information• to whom it was given.• the oral or written information or advice given to the patient, carer, other

authorised representative, care professional or other third party. May includeadvice about actions related to medicines or other ongoing care activities onan ‘information prescription’. State here if there are concerns about the extentto which the patient and / or carer understand the information provided aboutdiagnosis, prognosis and treatment.

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Distribution list

Element Description

Name If the communication is being sent to a named individual, then this is the name of the recipient, preferably in a structured format. An identifier for the individual, for example GMC code (for a GP), or an SDS identifier, an NHS Number (for a patient) will be sent alongside the name, but may not displayed on rendered document.






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Reason for referral (history)

Element Description


Clinical urgency of referral Referrer’s assessment of urgency (e.g. urgent / soon / routine). May include reason if other than routine, e.g. two data items: • level of urgency• reason.

Expectation of referral A clear statement of the expectations of the person making the referral as to the management of the patient, e.g. advice only, diagnosis, treatment, etc. To Include any specific patient expectation In general text. Risk not put in a procedure not already received.

Presenting complaints The list and description of the health problems and issues experienced by the or issues patient precipitating referral. This may include disease state, medical condition,

response and reaction to therapies, e.g. blackout, dizziness, chest pain, follow–up from admission, falls, a specific procedure, investigation, family history or treatment.

History of each presenting Information directly related to the development and characteristics of each complaint or issue presenting complaint (e.g. including travel history). Including if the information

is given by the patient or their carer.

Management to date Referrals, management, investigations and treatment that have already been undertaken, including patient managing their symptoms. Including: • procedures conducted – procedures carried out (and the date) and procedure report.

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Dose timing description A description of the frequency of taking or administration of a medication dose, e.g. “twice a day”, ”at 8am 2pm and 10pm”.


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Element Description

Additional instructions Allows for: • requirements for adherence support, e.g. compliance aids, prompts and packaging

requirements• additional information about specific medicines e.g. where specific brand required• person requirements, e.g. unable to swallow tablets.



Valid from date Date the prescription can be issued from. Valid for 6 months.




Repeat medications: This is the sub–section where all current repeat medications are recorded.


Form Form of the medicinal substance e.g capsules, tablets, liquid. Not normally required unless a specific form has been requested by the prescriber, e.g. “modified release capsules”.




Dose amount description A plain text description of medication single dose amount, as described in the AoMRC medication headings, e.g. “30 mg” or “2 tabs”. UK secondary care clinicians and systems normally minimally structure their dose directions, separating dose amount and dose timing (often referred to as dose and frequency). This format is currently used in GP systems, which can import dose and frequency descriptions concatenated into the single dose directions description.”


Dose timing description A plain text description of medication dose frequency, as described in the AoMRC medication headings, e.g. “twice a day”, “at 8am 2pm and 10pm”. UK secondary care clinicians and systems normally minimally structure their dose directions, separating dose amount and dose timing (often referred to as dose and frequency). This format is currently used in GP systems, which can import dose and frequency descriptions concatenated into the single dose directions description.



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Additional instructions Additional multiple dosage or administration instructions as plain text. This may include guidance to the prescriber, patient or person administering the medication. In some settings, specific administration instructions may be re– labelled as “patient advice’ or ‘dispensing Instruction’ to capture these flavours of instruction, e.g. “omit morning dose on day of procedure”, “for pain or fever”, “dispense weekly”.






For medications that have been changed, ie additions, amendments and discontinued, in addition to the above, also record:

Description of amendment Where a change is made to the medication ie one drug stopped and another started or dose, frequency or route is changed.

Indication Reason for change in medication, e.g. sub–therapeutic dose, patient intolerant. (for medication change)

Discontinued medication Date range of discontinued medications. extraction period


Form Form of the medicinal substance, e.g capsules, tablets, liquid. Not normally required unless a specific form has been requested by the prescriber, e.g. “modified release capsules”.

Route Optional medication route, using SNOMED CT terms where possible. Not generally applicable to product– based medication. Should not be used to specify a specific administration site, for which a separate archetype is used, e.g. the route is ‘intraocular’ the site may be ‘Left eye’, e.g. “oral”, “intraocular”. Note that this element supports multiple routes to allow a choice to be specified by the prescriber.

Site The anatomical site at which the medication is to be administered, “left eye”.


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Element Description






Date discontinued This is when the medication was stopped.

Reason for discontinuation Reason medication was discontinued.

Additional instructions Additional multiple dosage or administration instructions as plain text. This may include guidance to the prescriber, patient or person administering the medication. In some settings, specific administration instructions may be re– labelled as “patient advice’ or ‘dispensing instruction’ to capture these flavours of instruction, e.g. “omit morning dose on day of procedure”, “for pain or fever”, “dispense weekly”.

Prescribed elsewhere: Medication managed by another organisation.


Form Form of the medicinal substance e.g capsules, tablets, liquid. Not normally required unless a specific form has been requested by the prescriber, e.g. “modified release capsules”.

Route Optional medication route, using SNOMED CT terms where possible. Not generally applicable to product– based medication. Should not be used to specify a specific administration site, for which a separate archetype is used, e.g. the route is ‘intraocular’ the site may be ‘left eye’, e.g. “oral”,“intraocular”. Note that this element supports multiple routes to allow a choice to be specified by the prescriber.




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Element Description




Additional instructions Additional multiple dosage or administration instructions as plain text. This may include guidance to the prescriber, patient or person administering the medication. In some settings, specific administration instructions may be re– labelled as “patient advice’ or ‘dispensing instruction’ to capture these flavours of instruction, e.g. “omit morning dose on day of procedure”, “for pain or fever”, “dispense weekly”.



Organisation Prescribing organisation.



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Section Eight: Healthy child record

The structure and content for the health and care information to be recorded in the healthy child record by the relevant health and care

professional in any care setting.



GP practice

Element Description




GP Opt Out indicator Indication that parent / carer or child has opted out of registering with a GP.

Referrer details

Element Description

Referrer details Name, role, grade, organisation and contact details of referrer. If not an individual, this could be a GP surgery, department, specialty, sub–specialty, educational institution, mental health team etc. Also needs to include self–referral.

Date The date of referral.

Referral Method The form in which a referral is sent and received. This may be a letter, email, transcript of a telephone conversation, choose and book, in person (self–referral), unknown etc.

Referral to The type of service or team that the patient has been referred into, e.g. GP surgery, department, specialty, subspecialty, educational establishment, mental health etc.

Speciality referred from The type of service or team that the patient has been referred from.

Urgency of referral Referrer’s assessment of urgency (e.g. urgent / soon / routine).

Reason for Referral A clear statement of the purpose of the person making the referral, e.g. diagnosis, treatment, transfer of care due to relocation, investigation, second opinion, management of the patient (e.g. palliative care), provide referrer with advice / guidance. This may include referral because of carer’s concerns.


Element Description



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Element Description












Social context

Element Description

Family and Household Family and Household details of Social Context.


Accommodation status An indication of the type of accommodation where the child lives. This should be based on the main or permanent residence.

Father’s employment status The employment status of the Father and his occupation.

Household Social Whether or not any household member had / has social services support. Services support

Household(s) environment Factors in the household(s) which impact the child’s health and well-being, to include smoking in the home, alcohol / substance use etc.

Mother’s employment status The employment status of the Mother and her occupation.

Mother’s educational status The highest educational qualification attained by the child’s mother.

Other Significant Individuals People deemed as key by family and or Health Care Professional in the child’s life that do not live in the home (s).

Personal Personal details of Social Context.

Social circumstances The record of a patient’s social background, network and personal circumstances, eg housing, religious, ethnic and spiritual needs, social concerns and whether the patient has dependents or is a carer. May include reference to safeguarding issues that are recorded elsewhere in the record.

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Element Description

Lifestyle The record of lifestyle choices made by the patient which are pertinent to his or her health and well-being, e.g. the record of the patient’s physical activity level, pets, hobbies, and sexual habits


Alcohol intake Latest or current alcohol consumption observation

Drug / substance use Latest or current drug / substance use observation


Element Description


Accessible information – Requirement for a communication professional to be present in order to provide accessibility, with requires communication regard to disability. professional

Accessible information – Outlines capability and support required in order to in order to provide accessibility, with regard communication support to disability.

Accessible information – Requirement for a specific contact method in order to provide accessibility, with regard to disability. requires specific contact method

Accessible information – Requires information in a specific format in order to provide accessibility, with regard to disability. requires specific information format

Child or parent / carer / guardian An indicator of whether the individual requirement relates to the child or their primary carer.

Cognition An indicator of cognitive impairment to be considered when communicating related to the child or their primary carer.

Mobility needs A child or their primary carers personal physical movement between two spaces that achieves participation and a degree of independence.

Admission Details

Element Description


Admission method How the patient was admitted to hospital, e.g. elective, emergency, maternity, transfer etc.


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Element Description


Responsible consultant The name designation of the consultant, who has overall responsibility for the patient (may not actually see the patient).

Person accompanying patient Identify others accompanying the patient, e.g. relative, friend, informed carer, advocate. If the patient was not present was an authorised representative present? Includes name, relationship, (spouse, etc) role (patient advocate, etc).

Speciality Specialties designated by royal college and faculties, e.g. orthopaedics, renal medicine and endocrinology, etc.

Admitted to The ODS site code and description of where the child was admitted.

Discharge details

Element Description

Discharge destination The destination of the patient on discharge. National codes, e.g. high dependency unit.

Discharging consultant The consultant responsible for the patient at time of discharge.

Discharging specialty / The specialty or department responsible for the patient at the time of discharge. department


Date / time of discharge The actual date of discharge.

Discharge method The method of discharge from hospital. National codes, e.g. patient discharged on clinical advice or with clinical consent; patient discharged him / herself or was discharged by a relative or advocate; patient died; stillbirth.

Discharge address Address to which patient discharged. Only complete where this is not the usual place of residence.


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Problems and issues

Element Description


Clinical risks Description of clinical risks identified, e.g. problematic intubation, person with brittle diabetes, immuno–compromised / risk of infection etc.

Comment Any further textual comment to clarify, such as statement that information is partial or incomplete.

Diagnoses

Element Description




Date diagnosis made The date when the diagnosis was made.

Family history

Element Description


Condition or diagnosis The condition or diagnosis in family relations deemed to be significant to the care or health of the child.

Date The date the family history was recorded.

Maternal or paternal relation Record of whether the condition or diagnosis was on the mother’s or father’s side of the family, where needed, e.g. paternal grandfather.



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Assessment scales

Element Description

Assessment scale name The name of the overarching assessment scale used e.g. Bayley, Griffiths, Ages & Stages Questionnaire etc.



Global score The total global score from the assessment.


Performing professional Details of the professional performing the assessment scale (including name and role).



Legal information

Element Description

Looked after child Legal information for looked after child.

Child protection plan Legal information for child protection plan.

Local Authority The named local authority.

Safety alerts

Element Description







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Element Description

Causative agent The agent such as food, drug or substances that has caused or may cause an allergy, intolerance or adverse reaction in this patient. Or “no known drug allergies or adverse reactions” or “Information not available”.











Element Description

Patient concerns, Description of the concerns, wishes or goals of the person in relation to their care, as expressed by the expectations and wishes person, their representative or carer. Record who has expressed these (patient or carer / representative

on behalf of the patient). Where the person lacks capacity this may include their representative’s concerns, expectations or wishes.


Element Description




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Element Description




Element Description

Information and advice given This includes: • what information• to whom it was given.• the oral or written information or advice given to the patient, carer, other authorised representative,

care professional or other third party. May include advice about actions related to medicines or otherongoing care activities on an ‘information prescription’. State here if there are concerns about theextent to which the patient and / or carer understand the information provided about diagnosis,prognosis and treatment.





Element Description

Date The date on which the plan and requested actions was recorded.

Performing professional Details of the professional performing the plan and requested actions (including name and role).

Birth details

Element Description

APGAR score A set of observations made on the baby following birth to check adaptation to life outside the womb. This includes 1 minute, 5 minutes and 10 minutes.

Birth order The sequence in which this baby was born (one of one, one of two etc).

Birth weight Numeric value for weight at birth.

Date & time of birth The date and time of birth of the baby.

Delivery place type The type of place in which the baby was born, e.g. private health facility, domestic address, NHS hospital, midwifery led unit etc.

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Element Description

Fetal problems diagnosed Problems with the fetus diagnosed with screening or ultrasound. E.g. Down Syndrome, congenital heart before birth disease etc.

Length of gestation Gestational age in weeks and days (usually equivalent to length of pregnancy).


Maternal problems in Maternal medical conditions or infectious diseases arising in pregnancy which may have an impact on pregnancy the fetus, e.g. gestational diabetes, rubella etc.


Neonatal resuscitation Details of neonatal resuscitation measures required, e.g. chest compression, oxygen mask etc.

Physical problems detected Physical problems identified with the baby at, or shortly after, birth, e.g. cleft lip / palate, extensive at birth bruising, cephalohematoma etc.

Problems during delivery Problems experienced by the baby during delivery, e.g. cord prolapse, meconium aspiration, fetal distress etc.

Put To Breast Whether or not the baby was put to the breast.

Spontaneous respiration Details of neonatal resuscitation measures required, e.g. chest compression, oxygen mask etc.

Type of delivery Type of delivery for the baby, e.g. vacuum extraction, breech extraction, elective caesarean section etc.


Demographic history

Element Description



Patient address History of Patient’s usual place of residence.

Patient name Any previous names, aliases and preferred name. This will normally be given by a patient demographics service (PDS) patient trace, or the name of the patient held on the local patient administration system (PAS).

Patient telephone number History of telephone contact details of the patient. To include, e.g. mobile, work and home number if available.

Developmental skills

Element Description

Comments Supporting text may be given regarding the developmental skill.

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Element Description

Date first achieved The date the developmental skill was first achieved (developmental first) as reported by the parent. This is primarily for parent reporting as part of parent child health record at the time the skill is acquired.

Date of enquiry The date the parent or carer was asked by a health professional about the developmental skill (milestone).

Date of observation The date a health professional observed or tested a developmental skill (milestone).

Developmental Skill The name of the developmental skill, e.g. walks independently, smiles, finger feeds etc.

Result of enquiry Whether the developmental skill was achieved, not achieved or equivocal.

Result of observation Whether the developmental skill was achieved, not achieved or equivocal.

Educational history

Element Description

Educational assessment The outcome of an educational assessment.

Educational establishment Name of educational establishment.

Type of educational Phase / type of education establishment. establishment

Type of special The type of special educational needs for the child. educational need

Year from The year the child attended the school from.

Year to The year the child left the school.

Emergency care attendance

Element Description


Date and time of attendance Date and time patient arrived at the unscheduled care unit.


Diagnosis Confirmed diagnosis; active diagnosis being treated. Include the stage of the disease where relevant.

Discharge destination The destination of the patient on discharge. National codes. E.g. High Dependency Unit.


Location Details of where the unscheduled care attendance took place.

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Element Description

Person accompanying patient Identify others accompanying the patient, e.g. relative, friend, patient informal carer, advocate. If the patient was not present, was an authorised representative present. Include name and relationship (friend, relative, etc.).

Plan and requested actions A simple free text description of the plan of action following the contact with the child. This may include actions for the parent, healthcare professional, e.g. health visitor and review.

Presenting complaint or issue The health problem or issue experienced by the patient resulting in their attendance. This may include disease state, medical condition, response and reactions to therapies, e.g. blackout, dizziness, chest pain, follow up from admission, falls, a specific procedure, investigation or treatment.

Procedure The therapeutic or diagnostic procedure performed on the patient. This may be coded, or represented as free text.

Referral source Source of referral for unscheduled care.

Safety alerts Safety alerts at the emergency care attendance suggested to be pulled through from the safety alerts heading.

Feeding status

Element Description


Date breast milk feeding Date of last breast milk feed to the nearest month and year. stopped

Feeding concerns A record of any concerns about the baby’s feeding.

Feeding method A record of the predominant feeding method for the baby, e.g. breast fed, bottle / cup fed, gastronomy, nasogastric feeds etc.

First milk feed Whether or not the baby’s first feed was breast milk.

Introduction of solids Whether the baby has been introduced to solid foods at the time seen.

Milk feeding status of Whether the baby is totally breast milk fed, partially breast milk fed or not breast milk fed. To be the baby recorded each time a baby has contact with a health professional.

Health and well-being assessment and reviews

Element Description


Post birth review This details those checks and assessments done on the baby prior to leaving hospital that do not make up the NIPE screening.

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Element Description

New baby review The details captured as part of the new baby review.

6–8 week health visitor review The details captured as part of the 6–8 heath visitor review.

1 year review The details captured as part of the 1 year review.

2–2 1 / 2 year health and The details captured as part of the 2–2 1 / 2 health and development review. development review

school entry review The details captured as part of the school entry review including the outcome of the hearing and screening check.

Ad–Hoc health review The details captured as part of any ad–hoc health review undertaken.

Immunisations

Element Description





Indication The clinical indication or reason for administering the immunisation.



Name of immunisation Which immunisation has been administered (SNOMED CT code – list of available immunisations).

Outcome status Whether the vaccine was administered or not, including the reason why.





Vaccine product Vaccine product administered.

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Measurements

Element Description

BMI centile Child BMI centile calculated using the height / weight / gender and age of the child.

Date The date on which the measurement was recorded.

Head circumference Numeric value for the head circumference.

Height / length Numeric value for the body length.

Location The location where the measurement was recorded.

Performing professional Details of the professional performing the measurement (including name and role).

Weight Numeric value for weight.


Element Description

Newborn blood spot screening The details captured as part of the NBS programme which screens for sickle cell disease (SCD), cystic fibrosis (CF), congenital hypothyroidism (CHT) and inherited metabolic diseases (IMDs).

Newborn hearing screening The details captured as part of the NHSP programme which offers 2 types of test for babies: • automated otoacoustic emission (AOAE)• automated auditory brainstem response (AABR).

Newborn and infant physical The details captured as part of the NIPE programme which tests babies within 72 hours of birth for examination (72 hours) conditions relating to their:

• heart• hips• eyes• testes.

Newborn and infant The details captured as part of the NIPE programme which tests babies again at 6–8 weeks for physical examination conditions relating to their: (6–8 Weeks) • heart

• hips• eyes• testes.

Parent / guardian / personal comment

Element Description

Date Date the comment was entered and shared.

Who Who recorded the comment and what relationship they are to the child.

Parent / guardian or Free text comment made by the parent / guardian of the child, or the child themselves. personal comment

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Personal contacts

Element Description


Relationship The personal relationship the individual has to the child, e.g. father, grandmother, family friend etc.

Parental responsibility Flag to indicate whether the personal contact has parental responsibility.

Contact details Contact details of the person, e.g. telephone number, email address etc.

NHS Number The NHS number of the personal contact.


Element Description

Name / Team The name of the person or the team responsible.

Role The professional role the individual has in relation to the child, e.g. nursery nurse, health visitor, school nurse etc.)

Speciality The speciality of the professional responsible (e.g. health visiting, school nursing etc.)



Contact details Contact details of the person (e.g. telephone number, email address etc.)




Element Description




Quantity supplied The quantity of the medication, (e.g. tablets, inhalers, etc.) provided to the patient on discharge. This may be dispensed by the pharmacy or on the ward.



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Element Description







Structured dose A structural representation of dose amount, e.g. 20mg or 2 tablets This element will generally only amount cluster be used when persisting data within systems with ‘Parsable dose directions’ being used to exchange

the same information between systems.

Structured dose A slot containing a structural, computable representation of dose timing and maximum dose. timing cluster Comment: This element will generally only be used when persisting data within systems with

‘Parsable dose directions’ being used to exchange the same information between systems.

Additional instructions Allows for: • requirements for adherence support, e.g. compliance aids, prompts and packaging requirements• additional information about specific medicines e.g. where specific brand required• person requirements, e.g. unable to swallow tablets.











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Section Nine: Digital care and support plan

The structure and content for the health and care information to be recorded in digital care and support plans recorded in any care setting.



GP practice

Element Description





Element Description














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About me

Element Description

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

Date This is a record of the date that this information was last updated.

Supported to write this by Where relevant, this is a record of name, relationship / role and contact details of the person who supported the individual to write this section, e.g. carer, family member, advocate, professional.

Contingency plan(s)

Element Description

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

Anticipatory Medicines or equipment available that may be required in specific situations and their location. medicines / equipment

Contingency plan name Name of the contingency plan – what condition or circumstances it is addressing.

Date this plan was last updated This is a record of the date that this contingency plan was last updated.

Planned review date / Interval This is the date / interval when this contingency plan will next be reviewed.


Trigger factors Signs to watch out for that may indicate a significant change in health or other circumstances.

What should happen To record guidance on specific actions or interventions that may be required or should be avoided in specific situations. This may include circumstances where action needs to be taken if a carer is unable to care for the individual.

Who should be contacted Who should be contacted in the event of significant problems or deterioration in health or well-being including name, designation and contact details of persons.

Additional supporting plan(s)

Element Description

Additional supporting The name of the particular additional supporting plan, e.g. dieticians plan, wound management plan name discharge management plan.

Additional support plan content Insert this into description bow: This is the content of any additional care and support plan which the individual and / or care professional consider should be shared with others providing care and support. It should be structured as recommended for the care and support plan and if contains additional detail, it may be referenced here.


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Element Description

Person completing record This is the person contributing to the care and support plan. Should include their name, role, grade, specialty, organisation, professional identifier, date and time completed, contact details.



Date this plan was last updated This is a record of the date that this information was last updated.

Care and support plan

Element Description

Actions and activities Actions or activities the individual or others plan to take to achieve the individual’s goals and the resources required to do this. For each action the following may be identified: Stage goal – a specific sub–goal that is related to the overall goal as agreed by the person in collaboration with a professional What – what the action is and how it is to be carried out? Who – name and designation, e.g. person, carer, GP, OT, etc., of the person, or a team, carrying out the proposed action, and, if relevant where action should take place When – planned date, time, or interval, as relevant Suggested strategies for potential problems Status – not started, started, completed, not applicable Confidence – how confident the person feels to carry it out Outcome – the outcome of the stage goal Date when action / activity record was last updated Review date – when the stage goal and action need to be reviewed.

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

Care funding source A reference to the funding source and any conditions or limitations associated.

Date last updated Date when action / activity record was last updated.

Date this plan was last updated This is a record of the date that this care and support plan was last updated.

Goals and hopes The overall goals, hopes, aims or targets that the individual has. Anything they want to achieve that relates to their future health and well-being. 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 individual.

Needs, concerns or Needs, concerns or health problems an individual has that relate to their health and well–being. health problems

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Element Description

Other care planning documents Reference other care planning documents, including the type, location and date. This may include condition–specific plans, advance care plans, end of life care plan, etc.

Outcomes Outcomes of each of the individual’s goals, aims and targets. Includes comments recorded by the individual, date and status: fully achieved, partially achieved, not achieved, on–going, no longer applicable.



Strengths Any strengths and assets the individual has that relate to their goals and hopes about their health and well–being.

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Section Ten: Maternity record

The structure and content for the health and care information to be recorded in maternity services systems, GP systems and exchanged between

different providers of maternity car, in order to improve the care experienced by pregnant women and their babies.

Not all structured content will be used in all care settings or circumstances and the order in which they appear in the electronic patient record,


GP practice

Element Description




GP Opt Out indicator Indication that parent / carer or child has opted out of registering with a GP.

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Referrer details

Element Description

Date The date / time on which the referral was made.

Referrer details Name, role, organisation and contact details of referrer. If not a person, this could be e.g. GP surgery, department, specialty, sub-specialty, educational institution, mental health etc. Also needs to include the source of the referral i.e. self-referral.

Referral method The form in which the referral is sent and received.

Referral to The type of service or team that the woman has been referred into.

Referred from The type of service or team that the woman has been referred from.

Urgency of referral Referrer’s assessment of urgency (e.g. urgent / soon / routine).

Reason for Referral The primary presenting condition or symptom for which the woman was referred to a Specialist Service.

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Referrer details

Element Description

Patient name The full name of the woman. This will normally be given by a Patient Demographics Service (PDS) patient trace, or the name of the woman held on the local Patient Administration System (PAS).

Patient preferred name The name by which a woman wishes to be addressed.

Date of birth The date of birth of the woman.

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Element Description

Place of birth The town and country of birth of the woman.

Patient sex The woman’s phenotypic sex. Determines how the person will be treated clinically.

Gender As the woman wishes to portray themselves.


Other identifier Country specific or local identifier, e.g. Community Health Index (CHI) in Scotland. .

Patient address The woman’s usual place of residence.

Patient telephone number Telephone contact details of the woman. To include, e.g. mobile, work and home number if available.

Patient email address The email address of the woman.

Communication preferences The preferred contact method, e.g. sign language, letter, phone, etc. Also preferred written communication format, e.g. large print, braille.

Ethnicity The ethnicity of the woman.

Religion The religious affiliation as specified by the woman.

Marital status An indicator to identify the legal marital status of the woman.

Date of death The date of death of the woman (if applicable).

Time of death The time of death of the woman (if applicable). .

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Social context

Element Description

Family and household Family and Household details of Social Context.

Household composition Details of those living in the same household and their relationship with the woman. As recorded in Personal Contacts.

Other Significant individuals People deemed as key by family and or Health Care Professional in the woman’s life that do not live in the home(s).

Household environment Factors in the household which impact the woman’s health and well-being, to include smoking in the home, alcohol / substance use etc.

Accommodation status An indication of the type of accommodation where the woman lives. This should be based on the main or permanent residence.

Partner’s employment status The employment status of the Partner and their occupation.

Household social Whether or not any household member had / has social services support. services support


Personal Personal details of Social Context.

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Element Description

Social circumstances The record of the woman’s social background, network and personal circumstances, e.g. housing, religious, ethnic / spiritual needs and social concerns.

Lifestyle The record of lifestyle choices made by the woman which are pertinent to her health and well-being, e.g. the record of the physical activity level, diet, pets, hobbies, sexual habits etc.

Smoking Record of smoking status of the woman. To include CO screening. Also include the date stopped smoking and any types of nicotine replacement used.

Alcohol intake Record of alcohol consumption of the woman. This includes the number of drinking days per week and units of alcohol per day.

Drug / substance use Current recorded drug / substance use by the woman. This includes the drug / substance status and the type of drug.

Employment status The employment status of the woman and her occupation..

Educational status The highest educational qualification attained by the woman.

Asylum Status The asylum status of the woman.

Number of years in education The number of years that the woman has spent in education.

Social risk factors A record of social factors which should be taken into account when providing care and support for the woman and the child when born.


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Element Description

Accessible information – Outlines capability and support required in order to in order to provide accessibility, communication support with regard to disability.

Accessible information – Requirement for a communication professional to be present in order to provide requires communication accessibility, with regard to disability. professional

Accessible information – Requirement for a specific contact method in order to provide accessibility, requires specific with regard to disability. contact method

Accessible information – Requires information in a specific format in order to provide accessibility, with requires specific regard to disability. information format

Individual requirement Individual requirements that a woman has. These may be communication, cultural, cognitive or mobility needs related to themselves or their primary carer.

Mobility needs A woman’s personal physical movement between two spaces that achieves participation and a degree of independence.

Cognitive An indicator of cognitive impairment to be considered when communicating.

Comment Supporting text may be given regarding the individual requirement.

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Element Description

Research study details Name of the research study / trial and / or drug / intervention.

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Attendance details

Element Description

Date The date on which the contact took place.

Performing professional Details of the professional performing the contact.

Location Details of where the contact was performed.

Location type An indication of the type of location where the contact took place e.g. woman’s home.

Contact type The type of care contact.

Consultation method Consultation method used identifies the communication mechanism used to relay information between the Care Professional and the woman who is the subject of the consultation, during the contact.

Specialty Specialties designated by royal colleges and faculties. E.g. orthopaedics, renal medicine, endocrinology, etc.

Service Treatment functions or services. e.g. hand surgery, back surgery, hand clinic, TIA clinic, falls clinic, speech and language therapy, dialysis, family therapy, pre-admission assessment clinic, etc.

Care professionals present The name, designation of the additional individual’s or team members including consultant(s), nurse consultant(s), allied health professional(s), social worker(s).

Person accompanying woman Identify, where clinically relevant, others accompanying the woman, e.g. relative, friend, informal carer, advocate. If the woman was not present, was an authorised representative present? Includes: Name, Relationship, Role (woman’s advocate).

Outcome of contact This records the outcome of a contact.

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Admission details

Element Description

Date and time of admission Date / time on which the woman was admitted to hospital.

Admitted to The ODS Site Code and description of where the woman was admitted.

Responsible clinician The name and designation of the clinician, who has overall responsibility for the woman (may not actually see the woman).

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Element Description

Speciality Specialties designated by royal colleges and faculties. E.g. orthopaedics, renal medicine, endocrinology, etc.

Source of admission Where the woman was immediately prior to admission, e.g. usual place of residence, temporary place of residence, penal establishment.

Person accompanying woman Identify others accompanying the woman, e.g. relative, friend, woman informal carer, advocate.

Reason for admission The specific reason that prompted the decision to admit to hospital e.g. chest pain, blackout, fall, myocardial infarction, a specific procedure, investigation or treatment.

Admission method How the woman was admitted to hospital. For example: elective, emergency, maternity, transfer etc.

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Discharge details

Element Description


Discharged from The ODS Site Code and description of where the discharge was from.

Discharging clinician The clinician responsible for the woman at time of discharge.

Discharging specialty / The specialty / department responsible for the woman at the time of discharge. department

Discharge method The method of discharge from hospital.

Discharge destination The destination of the woman on discharge from hospital.

Discharge address Address to which the woman is discharged. Only completed where this is not the usual place of residence.

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Element Description

Date The date on which the clinical risk factor was recorded.

Location The location where the clinical risk factor was recorded.

Performing professional Details of the professional recording the clinical risk factor (including name and role).

Clinical risk factor Factor shown to be associated with the development of a medical condition that poses a risk the woman, fetus, or the child after birth. For example gestational diabetes or hypertension.

Clinical risk assessment Specific assessments undertaken in relation to the risk.

Risk mitigation Actions taken to reduce the clinical risk.

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Problem list

Element Description

Date recorded The date on which the problem was recorded.

Performing professional Details of the professional recording (including name and role).

Location Details of where the problem was recorded.

Problem A condition which needs addressing and so is important for every health professional to know about when seeing the woman. Problems may include diagnoses, symptoms, disabilities and social or behavioural issues, and comprise the ‘Problem list’.

Date A date or estimated date that the Problem began.

End date The date or estimated date the problem was resolved (will be blank for active).

Stage of disease The stage of the disease where relevant.

Comment Supporting text may be given covering the problem.

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Medical history

Element Description

Date The date on which the medical history was recorded.

Location The location where the medical history was recorded.

Performing professional Details of the professional performing the medical history (including name and role).

Gynaecology 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.

Past obstetric A record of the woman’s obstetric medical history relevant to the maternity episode. To include each previous pregnancy details and the outcome.

Relevant past medical history The record of the patient’s significant medical, history. Including relevant previous diagnoses, health history problems and issues.

Relevant past surgical history The record of the patient’s significant surgical history. Including relevant issues, procedures, investigations, specific anaesthesia issues, etc.

Relevant past mental A record of the woman’s mental health history relevant to the maternity episode. health history

Acute Hospital Episodes Reported details of any history of acute hospital episodes including ITU, HDU and A&E attendances the woman has had.

Mental Health Admissions Reported details of any history of mental health admissions.

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Procedures

Element Description

Date The date on which the procedure was recorded.

Location The location where the procedure was recorded.

Performing professional Details of the professional performing the procedure (including name and role).

Procedure The details of the therapeutic or diagnostic procedure performed.



Complications related Details of any intra-operative complications encountered during the procedure, to procedure arising during the woman’s stay in the recovery unit or directly attributable to the procedure.


Comment Supporting text may be given regarding the procedure.

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Family history

Element Description

Family history of women

Date The date on which the family history was recorded.

Location The location where the family history was recorded.

Condition or diagnosis The condition or diagnosis in family relations deemed to be significant to the care or health of the woman.

Relationship to woman The relationship of the person with the condition to the woman.



Family history of fetus

Date The date on which the genetic history was recorded.

Location The location where the genetic history was recorded.

Condition or diagnosis The condition or diagnosis in family relations of the fetus deemed to be significant to the care or health of the fetus during pregnancy.

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Element Description

Relationship to fetus The relationship of the person with the condition to the fetus.



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Element Description

Date The date on which the investigation was performed.

Performing professional Details of the professional performing the investigation (including name and role).

Location The location where the investigation was recorded.


Investigation result For each investigation, the result of the investigation (this includes the result value, with unit of observation and reference interval where applicable, interpretation of the results and date.

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Assessment scales

Element Description



Performing professional Details of the professional the assessment scale (including name and role).

Assessment scale name The name of the overarching assessment scale used eg.PHQ-9 GAD 7 , Maternity Payment Pathway etc.

Total score The total score from the assessment.




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Safeguarding

Element Description

Date The date on which safeguarding details were recorded.

Location The location where the safeguarding details were recorded.

Performing professional Details of the professional recording the safeguarding details (including name and role).

Safeguarding Details of the concern, risk or issues in relation to safeguarding.


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Safety alerts

Element Description




Risks to self Risks the woman poses to themselves, e.g. suicide, overdose, self-harm, self-neglect.


Risk from others Details of where the woman is at risk from an identified person, e.g. family member.

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Element Description


Causative agent The agent such as food, drug or substances that has caused or may cause an allergy, intolerance or adverse reaction to this woman.

Date first experienced When the reaction was first experienced. May be a date of partial date (e.g. year) or text (e.g. during childhood).

Description of reaction A description of the manifestation of the allergic or adverse reaction experienced by the woman. For example, skin rash.



Type of reaction The type of reaction experienced by the woman (allergic, adverse, intolerance).

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Element Description



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Element Description

Date The date on which the concerns, wishes or goals of the woman were recorded.

Maternity care plan type The stage of maternity to which the care plan applies e.g. antenatal.

Planned delivery setting The planned delivery setting where the pregnant woman plans to have her baby as designated by the Care Professional in consultation with the woman.

Reason for change of The reason why the planned delivery setting has changed. planned delivery setting

Person and carer concerns, Description of the concerns, wishes or goals of the woman in relation to their care, expectations and wishes as expressed by the woman, their representative or carer. Where the woman lacks capacity this may include their representative’s concerns, expectations or wishes.

Advance statement Written requests and preferences made by a woman with capacity conveying their wishes, beliefs and values for their future care should they lose capacity. Include the location of the document if known.

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Element Description

Date The date on which the examination was recorded.



General appearance The record of a clinician’s ‘first impression’ assessment including general clinical examination finding, e.g. clubbing, anaemia, jaundice, obese / malnourished / cachectic, height, weight, etc.

Observations The record of essential physiological measurements, e.g. heart rate, blood pressure, temperature, pulse, respiratory rate, oxygen saturation. Use of National Early Warning Score (NEWS) chart where appropriate.

Mental health examination The record of findings from mental health examinations and, where appropriate, the type of the examination.


Oral examination The record of findings from the oral examination.

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Element Description

Cardiovascular examination The record of findings from the cardiovascular system examination.

Respiratory examination The record of findings from the respiratory system examination.

Obstetric and Gynaecology The record of findings from the obstetric examination e.g. abdominal uterine palpation, examination (including striations or Linea Nigra and whether she has previous operative scars, such as abdominal and uterine previous caesarean section. To include the record of findings from the vaginal palpation) examination, including FGM, presentation, moulding, membranes, observation of liquor and general cervical observations and contractions (including the strength, length and frequency), uterus size etc.

Neurological system examination The record of findings from the neurological system examination.

Musculoskeletal examination The record of findings from the musculoskeletal examination.

Dermatology examination The record of findings from the examination of the skin.

Abdomen examination The record of findings from the abdominal examination.

Genitourinary examination The record of findings from the genitourinary examination.

Comments Supporting text may be given regarding the examination.

Fetal examinations To be recorded one per fetus.

Fetal movements To be completed for each fetus and includes the examination of fetal movements, fetal heart rate, summary of CTG baseline (bpm) and decelerations.

Presenting part The presenting part of the fetus.

Lie The lie of the fetus.

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Element Description




Information and advice given This includes – what information (including health promotional messages) – to whom it was given. The oral or written information or advice given to the woman, carer, other authorised representative, care professional or other third party. May include advice about actions related to medicines or other ongoing care activities on an ‘information prescription’. State here if there are concerns about the extent to which the woman and / or carer understands the information provided about diagnosis, prognosis and treatment.

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Baby details (woman)

Element Description

Name The given name as recorded by the midwife.


Baby identifier Baby identifier details.

Gender The person’s phenotypic sex. Determines how the person will be treated clinically.

Birth order Where the baby is one of a multiple birth, to include the total number of offspring and to include whether the baby is identical to one of the siblings.


Birth weight Numeric value for weight of the baby at birth.

Gestation Gestational age in weeks and days (usually equivalent to length of pregnancy).

Birth outcome The birth outcome of each fetus.

APGAR The APGAR Score of the neonate at 1, 5 and 10 minutes and the component scores used to calculate the score.

Rhesus status An indication of whether the fetus has or does not have the rhesus factor (or Rh D antigen) on the surface of their red blood cells, using the Rh System.

Congenital abnormalities (Yes no field) as per NHSDD and recorded on Birth Notification.

Investigations requested To include any investigations requested including post mortem investigations).

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Demographic history

Element Description

Patient name Any previous names, aliases and preferred name. This will normally be given by a Patient Demographics Service (PDS) patient trace, or the name of the woman held on the local Patient Administration System (PAS).



Patient address History of the woman’s usual place of residence.

Patient telephone number History of Telephone contact details of the woman. To include, e.g. mobile, work and home number if available.

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Immunisations

Element Description




Name of immunisation Which immunisation has been administered with relevant part number (SNOMED CT code – list of available immunisations).

Vaccine product Vaccine product administered (DM+D code).







Outcome status Whether the vaccine was administered or not.


Indication The clinical indication or reason for administering the immunisation where relevant.

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Element Description

National screening programme The overarching screening programme. e.g. - NHS Fetal Anomaly Screening Programme - NHS Infectious Diseases in Pregnancy Screening Programme - NHS Sickle Cell and Thalassaemia Screening Programme.

Specific test performed The specific screening test performed, e.g. Combined test, Quadruple test, HIV, Syphilis etc. This may include site and laterality where applicable.

Screening test outcome The overall outcome of the screening test (this may include the status e.g. declined, deferred etc.).

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Personal contacts

Element Description


Relationship The personal relationship the person has to the woman (e.g. father, grandmother, family friend etc.).

Parental responsibility Flag to indicate whether the personal contact has parental responsibility if the woman is underage.

Household member Status identifying whether the personal contact is a member of the same household.

Contact details Contact details of the person (e.g. telephone number, email address etc.)

NHS Number The NHS number of the personal contact.

Next of Kin The primary person to contact in the event of an emergency or other situation.

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Element Description

National antenatel screening programme

NHS fetal anomaly The details captured as part of the NHS Fetal Anomaly Screening Programme screening programme – which screens for Down’s, Edwards’ and Patau’s syndromes. Down’s, Edwards’ and Patau’s Syndromes.

NHS fetal anomaly The details captured as part of the NHS Fetal Anomaly Screening Programme screening programme – which screens for fetal anomalies. structural anomalies

NHS infectious diseases The details captured as part of the NHS Infectious Diseases in Pregnancy in pregnancy screening Screening Programme which screens for Hepatitis B, HIV and Syphilis programme via a blood test. Chlamydia for under 25s and Hepatitis C can be recorded here as required.

NHS Sickle Cell and The details captured as part of the NHS Sickle Cell and Thalassaemia Thalassaemia screening Screening Programme which screens to find out if the woman is a carrier programme of the sickle cell or thalassaemia gene and therefore likely to pass it on to the baby. This may also be applicable to the baby’s father if the woman is identified as a carrier of a haemoglobin disease.

NHS Diabetic Eye The details captured as part of the NHS Diabetic Eye Screening Programme Screening Programme which is offered to women with diabetes in pregnancy.

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Element Description

Name / team The name of the person or the team responsible.

Role The role of the care professional in relation to the woman (e.g. Midwifery, Mental Health etc.).

Speciality The speciality of the professional responsible (e.g. Health Visiting, Mental Health etc.).






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Legal information

Element Description

Consent for This is a record of consent for information sharing. Where consent has been not information sharing been obtained or sought, the reason why must be provided. Include best interests decision where person lacks capacity.

Consent relating to child Consideration of age and competency. Record of person with parental responsibility or appointed guardian where child lacks competency.

Mental capacity assessment Whether an assessment of the mental capacity of the woman has been undertaken, if so, what capacity the decision relates to, who carried it out, when and the outcome of the assessment. Also record best interests decision if woman lacks capacity.

Deprivation of liberty Record of Deprivation of Liberty Safeguards (DoLS) or equivalent, including the safeguards or equivalent reason for this.

Mental Health Act or Record where a woman diagnosed with a mental disorder is formally detained equivalent status under the Mental Health Act or equivalent, including the section number and start date, start time and end date. If person subject to Community Treatment Order or Conditional Discharge (or equivalent) record here.

Advance decision to A record of an advance decision to refuse one or more specific types of future refuse treatment (ADRT) treatment, made by a woman who had capacity at the time of recording the decision. The decision only applies when the woman 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 woman’s life is at risk.

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Element Description

Lasting power of attorney Record of one or more people who have been given power (LPA) by the woman for personal welfare or when they had capacity to make decisions about their health and welfare should court-appointed deputy they lose capacity to make those decisions. To be valid, an LPA must have been (or equivalent) registered with the Court of Protection. If life-sustaining treatment is being considered the LPA document must state specifically that the attorney has been given power to consent to or refuse life-sustaining treatment. Details of any person (deputy) appointed by the court to make decisions about the woman’s health and welfare. A deputy does not have the power to refuse life-sustaining treatment.

Looked after child

Local authority The named local authority for the looked after child.

Looked after child start date Start date of a ‘looked after child’.

Looked after child end date End date of a looked after child’.

Child protection plan

Local authority The named local authority for the child protection plan.

Child protection plan start date Start date of a child protection plan.

Child protection plan end date End date of a child protection plan.

Unborn Child protection plan

Local authority The named local authority for the unborn child protection plan.

Unborn child protection Start date of an unborn child protection plan. plan start date

Unborn child protection End date of an unborn child protection plan. plan end date

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Element Description

Date The date on which the Plan and Requested Actions was recorded.

Performing professional Details of the professional recording the Plan and Requested Actions (including name and role).

Actions for healthcare Including planned investigations, procedures and treatment for a woman’s identified professionals conditions and priorities. For each action the following should be identified: outcome expectations, including the woman’s expectations.

Actions for woman or For each action the following should be identified: outcome expectations, their carer including the woman’s expectations.

Agreed with woman or Indicates whether the woman or legitimate representative has agreed the entire plan legitimate woman or individual aspects of treatment, expected outcomes, risks and alternative treatments. representative

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Personal comment / plan

Element Description

Date The date on which the comment was entered and shared.

Person Details Who recorded the comment and what relationship they are to the woman.

Personal comment Free text comment recorded by the woman or her representative.

Maternity Personalised Care Plan Personalised care plan details to include the data and plan details.

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Pregnancy episode details

Element Description

Pregnancy ID Identifier used to tie together data relating to a specific pregnancy, allowing specific contacts and activities carried out (e.g. scans, tests, observations, findings, diagnoses) to be linked back to the booking appointment for that pregnancy.

Fetal identifier Identifier which allows woman babies to be identified in the event of multiple births, and in turn allow specific conditions to be attributed to specific babies and linked to labour / antenatal test details.

Maternity episode start date The start date of the maternity episode.

Maternity episode end date The end date of the maternity episode.

Maternity episode end reason The reason that the woman was discharged from maternity services.

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Pregnancy outcome delivery and birth

Element Description

Date The date on which the pregnancy outcome / delivery / birth details were recorded.

Location The location where the pregnancy outcome / delivery / birth details was recorded.

Performing professional Details of the professional recording the pregnancy outcome / delivery / birth details (including name and role).

Pregnancy outcome The pregnancy outcome of each fetus.

Birth

Labour onset method Details of the method by which the process of labour began, or delivery by caesarean section occurred.

Date and time of The Date / time when established labour is confirmed – regular painful contractions established labour and progressive cervical dilatation.

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Element Description

Date and time fully dilated The date and time that the woman is deemed to be fully dilated.

Duration of 1st Stage A derived field based on the time of established labour to the time of full dilation.

Onset of 2nd stage of labour The date and time that the second stage of labour was deemed to start.

Date and time The date and time that pushing commenced. pushing commenced


Delivery place type The type of place in which the baby was born (e.g. Private health facility, domestic address, NHS hospital, midwifery led unit etc.).

Birth Attendants People present at the delivery.

Ruptured membranes Date / time on which membranes ruptured if spontaneous. Date / time

Duration of rupture The duration in hours and minutes as derived using the date of rupture versus of membranes current date time.

Anaesthesia type The specific type of anaesthesia used to carry out the procedure (if applicable).

Pain relief A record of pain relief used during labour and delivery where not anaesthetic or medication.

Delivery decision date / time The date and time of the decision to deliver.

Delivery decision made by The details of the clinician making the decision to deliver.

Reason for delivery decision The details of the reason for the decision to deliver.

Date and time of delivery The date and time of the delivery of the baby.

Duration of second stage Derived field from the onset of the second stage to the date and time of delivery.


Type of delivery Type of delivery for the baby, e.g. Spontaneous vaginal, vacuum extraction, breech extraction, elective caesarean section etc.

Length of labour The length of the stages of labour and duration of the rupture of membranes (derived field).

Delayed cord clamping / duration Record the duration of which cord clamping occurred.

Placenta delivery method The method by which the placenta was removed through physiological, active or manual means. Where more than one method is used, the final method should be recorded.

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Element Description

End of third stage The date and time of the end of the third stage of labour.

Third stage duration The duration of the third stage of labour derived between the start of the third stage and the delivery of the placenta.

Examination of placenta A visual examination of the placenta to check completeness.

Placenta disposal The method by which the placenta was disposed.

Placenta sent for histology An indication as to whether the placenta was sent for histology.

Umbilical cord number The number of umbilical cord vessels. of Vessels

Total blood loss The total volume of blood loss in mls following delivery.

Comments Supporting text may be given covering regarding the outcome of the checks and actions taken.

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Scan details

Element Description

Date The date on which the scan was performed.

Performing professional Details of the professional performing the scan (including name and role).

Location The location where the scan was recorded.

Scan The type of scan performed.

Scan finding For each pregnancy scan, the finding of the scan (this includes the result value, with unit of observation and reference interval where applicable.

Comment Supporting text may be given regarding the scan.

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Professional comment

Element Description

Date The date on which the professional summary / comment was recorded.

Location The location where the professional summary / comment was recorded.

Performing professional Details of the professional performing the professional summary / comment (including name and role).

Professional summary Summary of the encounter. Where possible, very brief. This may include interpretation of findings and results, opinion and specific action(s). Planned actions will be recorded under ‘plan’.

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Element Description





Site The anatomical site at which the medication is to be administered, e.g. “Left eye”.


Dose amount description A description of the medication single dose amount e.g. “30 mg” or “2 tabs”.

Dose timing description “A description of the frequency of taking or administration of a medication dose. e.g. ”Twice a day”, “At 8am 2pm and 10pm”.

Dose directions description A single plain text phrase describing the entire medication dosage and administration directions including dose quantity and medication frequency. Comment, e.g. “1 tablet at night or “2mg at 10pm”. This is the form of dosage direction text normally available from UK GP Systems.


Structured dose A structural representation of the elements carried by the dose syntax in direction cluster ‘Parsable dose Strength / timing’ i.e. dose strength, dose timing, dose duration and maximum dose.

Structured dose amount cluster A structural representation of dose amount. Comment: e.g. 20mg or 2 tablets This element will generally only be used when persisting data within systems with ‘Parsable dose directions’ being used to exchange the same information between systems.

Structured dose timing cluster A slot containing a structural, computable representation of dose timing and maximum dose. This element will generally only be used when persisting data within systems with ‘Parsable dose directions’ being used to exchange the same information between systems.

Additional instructions Allows for: * requirements for adherence support, e.g. compliance aids, prompts and packaging requirements * additional information about specific medicines e.g. where specific brand required * person requirements, e.g. unable to swallow tablets.

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Element Description

















Total dose daily The total daily dose of this medication. This is helpful for estimating optimal quantity cluster adherence to dosing guidance. It may be computed from product / dose strength and frequency or entered manually.





Name of discontinued medication The name of the medication or medical device being discontinued.



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Appendix One: Endorsement

The PRSB transfer of care and integrated care standards have been endorsed by PRSB member organisations as follows:

Association of British Paediatric Nurses

Association of Directors of Adult Social Services (ADASS)*

Association of Palliative Medicine

Association of UK Dieticians (BDA)

British & Irish Orthoptic Society.

British Academy of Childhood Disability

British Association of Community Child Health

British Association of Perinatal Medicine*

British Psychological Society

Care Providers Alliance

College of Paramedics

College of Paramedics

Community Practitioners and Health Visitors Association

Institute of Health Records and Information Management

National Council of Palliative Care

Public Health England

RCGP

RCN

RCOG

Resuscitation Council UK

Royal College of Anaesthetists

Royal College of Emergency Medicine

Royal College of Midwives

Royal College of Occupational Therapists

Royal College of Paediatrics & Child Health

Royal College of Physicians

Royal College of Psychiatrists

Royal College of Radiologists Faculty of Clinical Oncology*

Royal College of Surgeons

Royal Pharmaceutical Society

TechUK

The Chartered Society of Physiotherapy

The Royal College of Speech and Language Therapists

To support this new publication, PRSB Standards for the Structure and Content of Health and Care Records, the PRSB will be asking for continued endorsement from 46 organisations that endorsed the 2013 published standards. They are as follows: College of Paramedics

College of Physiotherapy

Royal College of Anaesthetists

Royal College of Emergency Medicine

Royal College of General Practitioners

Royal College of Midwives

Royal College of Nursing

Royal College of Nursing

Royal College of Obstetricians and Gynaecologists

Royal College of Occupational Therapists

Royal College of Paediatrics and Child Health Royal College of

Pathologists

Royal College of Physicians

Royal College of Psychiatrists

Royal College of Radiologists

Royal College of Speech and Language Therapy

Royal College of Surgeons

Royal Pharmaceutical Society

Specialist societies:

Association for Clinical Biochemistry

Association for Palliative Medicine of Great Britain & Ireland

Association of British Clinical Diabetologists

Association of Cancer Physicians

British Association for Sexual Health and HIV

British Association of Audiovestibular Physicians

British Association of Dermatologists

British Association of Plastic Reconstructive and Aesthetic

Surgeons

British Association of Stroke Physicians

British Association of Urological Surgeons

British Cardiovascular Society

British Dietetic Association

British Geriatrics Society

British Infection Association

British Orthodontics Society

British Pain Society

British Society for Gastroenterology

British Society for Haematology

British Society for Immunology

British Society of Rheumatology

British Thoracic Society

ENT–UK

Health and social care leadership and management

Institute of Health Records and Information Managers (IHRIM)

Renal Association

Royal College of Opthalmologists

Society of British Neurological Surgeons

Industry:

TechUK

INTEROPen

*These organisations provided a statement of support for the detailed standards.

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Appendix


Appendix Two: 2013 Structured content not currently used in use cases (2018)

Referrer details

Element Description Changes since 2013

Person to attend with patient Identify others who will / may accompany the patient, e.g. relative, carer, chaperone. Includes: • name • relationship (friend, relative, etc) • role (patient advocate, chaperone etc) • attendee’s special requirements.

Included in core headings in 2013, not in use cases

Diagnoses


Episode (first, new, • First episode. other, ongoing) • New episode. • Other, past or ongoing episode.

Date of first presentation The date the diagnosis or condition first presented.

Differential diagnosis The determination of which one of several diseases may be producing the symptoms.



Covered in clinical risk factors



General appearance The record of a clinician’s ‘first impression’ assessment including general clinical examination findings, e.g., clubbing, pallor, jaundice, obese / malnourished / cachectic, height, weight, etc.

Mental state Formal mental state examination or general description, e.g. depression, anxiety, confusion, delirium, dementia.

Cardiovascular system The record of findings from the cardiovascular system examination (including electrocardiogram [ECG] etc).

Respiratory system The record of findings from the respiratory system examination.

Abdomen The record of findings from the abdominal examination.

Musculoskeletal system The record of findings from the musculoskeletal system examination.

Covered in examination findings






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Skin The record of findings from examination of the skin.

Nervous system The record of findings from the nervous system examination.

Genitourinary The record of findings from the genitourinary examination.


Oral examination The record of findings from oral examination.

Obstetrics and gynaecology The record of relevant findings related to obstetrics and gynaecology.

Major trauma The record of relevant findings related to major trauma.

Examination procedure A procedure completed as part of the examination of the patient, e.g. sigmoidoscopy, lumbar puncture, pleural tap, etc

Medicine administered Record of administration to the person, including self–administration.











Reason for non–administration Reason why drug not administered, e.g. patient refused, patient not available, drug not available.

Relevant previous medications Record of relevant previous medications.

Medication status Whether or not a medication is currently used, previously used or authorised for future use.





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