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Name
PRSB Record structure and content
Description

Professional Record Standards Body (PRSB) - better records for better care

The PRSB develops national standards for the structure and content of health and social care records. These cover, for example, hospital referral letters, handover communications, discharge summaries, and inpatient and outpatient letters.

The standards are currently published in the form of a final report with supporting documents including: information models and implementation guidance. The information models are published in the following formats:
  • Mind maps
  • Microsoft Word Documents and
  • Excel spreadsheets
Many of the information models are common across the range of standards we have now developed, and we needed a tool to support all aspects of managing the models through their full life cycle including development and maintenance.

Transfers of care

  • Admission record: the clinical, professional and personal information recorded in the hospital admission record at the time of admission.
  • Handover record: handover of care from one professional or team to another including out of hours handover, or at the weekend.
  • Discharge records: the information recorded in all discharge records sent from hospital services (including acute care discharge, mental health discharge and emergency care discharge) to GPs.
  • Outpatient letters: the information recorded in an outpatient setting/ appointment including the initial and follow up outpatient visits and information in the outpatient letter sent to the GP and patient.
  • Crisis care: the information shared between GPs and primary care with emergency care, ambulance services and community care during an emergency or acute episode.
  • Clinical referral information: the information recorded in communication between GPs and consultants, copied to the patient. This may include other types of referrals. (Section Seven)

Integrated care records

  • Healthy child record: the information recorded by the multi–disciplinary team on screening tests, immunisations and developmental milestones that should be accessible to ensure that children receive appropriate care.
  • Digital care and support plan: the information recorded in a multi–disciplinary care and support plan including clinical, professional as well as the patient’s own preferences and needs.
PropertiesPrefix: prsb03-Default language: en-GBContains reusable content?The contents of this 'project' are considered suitable for re-use by other projects when this setting is active.Is private?The project is not listed in the menus and ignored in searches when this setting is active. This useful for projects in incubation fase. You may still work in the project based on direct URLsExperimental/Test?Project is experimental or meant to test things rather than aimed at production useNotifier: Determines the project global issue notifier setting (on/off - default is 'on'). Note: changes to this setting are immediately saved.
Publication location
 http://pub.art-decor.org/prsb/
Project overviewProject Index
Project Id2.16.840.1.113883.3.1937.777.28
Project Last modified2022-01-17 16:28:04
Repository reference
RESTful Service
PurposeURLFormat
FHIRhttp://art-decor.org/fhir/4.0/4.0
Contributors/Copyright
ContributorTypeLogoCopyright years
The Professional Records Standards Body
The Professional Record Standards Body (PRSB)
W theprsb.org
Author2018-2022
Authors
NameEmailSubscribe to all issuesEvery author is notified by default for events on issues where he is the author or from the moment he is assigned to an issue. If you would like to keep track of all issue updates, set this to 'on'
AdministratorNot visibleThis info is only visible to this author and any decor-admin authorNot visibleThis info is only visible to this author and any decor-admin author
Dr. Kai HeitmannNot visibleThis info is only visible to this author and any decor-admin authorNot visibleThis info is only visible to this author and any decor-admin author
Sandip KaurNot visibleThis info is only visible to this author and any decor-admin authorNot visibleThis info is only visible to this author and any decor-admin author
Tom HobbsNot visibleThis info is only visible to this author and any decor-admin authorNot visibleThis info is only visible to this author and any decor-admin author
Martin OrtonNot visibleThis info is only visible to this author and any decor-admin authorNot visibleThis info is only visible to this author and any decor-admin author
Jan HoogewerfNot visibleThis info is only visible to this author and any decor-admin authorNot visibleThis info is only visible to this author and any decor-admin author
Darren WooldridgeNot visibleThis info is only visible to this author and any decor-admin authorNot visibleThis info is only visible to this author and any decor-admin author
Haroldas PetkusNot visibleThis info is only visible to this author and any decor-admin authorNot visibleThis info is only visible to this author and any decor-admin author
Nicola QuinnNot visibleThis info is only visible to this author and any decor-admin authorNot visibleThis info is only visible to this author and any decor-admin author
Sheena JagjiwanNot visibleThis info is only visible to this author and any decor-admin authorNot visibleThis info is only visible to this author and any decor-admin author
Alannah McGovernNot visibleThis info is only visible to this author and any decor-admin authorNot visibleThis info is only visible to this author and any decor-admin author
Kasmyn ChenNot visibleThis info is only visible to this author and any decor-admin authorNot visibleThis info is only visible to this author and any decor-admin author
Holly KearnNot visibleThis info is only visible to this author and any decor-admin authorNot visibleThis info is only visible to this author and any decor-admin author
Sarah JacksonNot visibleThis info is only visible to this author and any decor-admin authorNot visibleThis info is only visible to this author and any decor-admin author
Annette GilmoreNot visibleThis info is only visible to this author and any decor-admin authorNot visibleThis info is only visible to this author and any decor-admin author
James CritchlowNot visibleThis info is only visible to this author and any decor-admin authorNot visibleThis info is only visible to this author and any decor-admin author
Ejeh KingsleyNot visibleThis info is only visible to this author and any decor-admin authorNot visibleThis info is only visible to this author and any decor-admin author
Max GattlinNot visibleThis info is only visible to this author and any decor-admin authorNot visibleThis info is only visible to this author and any decor-admin author
Fatima HaidareeNot visibleThis info is only visible to this author and any decor-admin authorNot visibleThis info is only visible to this author and any decor-admin author
Sharon HanleyNot visibleThis info is only visible to this author and any decor-admin authorNot visibleThis info is only visible to this author and any decor-admin author
Malcolm MundyNot visibleThis info is only visible to this author and any decor-admin authorNot visibleThis info is only visible to this author and any decor-admin author
Versions / Releases
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Ready
DateByDescriptionStatusPublication
2021-10-01 14:05:26Sandip KaurRelease: Version 3.2 transfers of care
Errors found with 3.1 and updated to 3.2 for all transfers of care. (details in scenarios)
Emergency care updated valuesets as per the ECDS v 3.1.0
Under pre-publication review
2021-09-28 17:30:02Sandip KaurRelease: Version 3.2 E-discharge
Updated to version 3.2 due to changes below:-
-'Formulation' and 'Family History' removed as erroneously added
- Slight update to MROs for demographic element in Person Name and Person Address, for alignment to other standards
Under pre-publication review
2021-09-24 16:13:48Sandip KaurRelease: Version 0.2 111 referral
updated due to incorrect elements added into V0.1
Under pre-publication review
2021-09-23 19:25:38Sandip KaurRelease: Version 0.1 111 referral
Draft 111 referral for piloting
Under pre-publication review
2021-09-21 18:16:18Sandip KaurRelease: Version 3.1 Transfers of care
eDisharge summary 3.1
-Updates to medication value sets
-MROs updated to reflect published version (2.1)
Under pre-publication review
2021-08-28 16:25:59Sandip KaurRelease: Version 2.0 Core information standard

Updates v 2.0have been made as part  of the logical model project  to:   

  • Alignment with other completed standards  projects since the previous release (Dec 2018).   

  • Maintenance issues  logged since the previous release.   

  • Updated  more succinct   valuesets  for many elements  for mapping to latest release of SNOMED CT, NHS data dictionary  and  to align to  UK core R4 FHIR profiles    

  • FHIR Target  added to represent the link to the UK core FHIR R4 where clinical and technical assurance has taken place  

  • Datatypes  added to reflect a logical model  

  • Standard JSON extract exported to SPARX  EA  and  UML entity and attribute diagrams developed  

  • SNOMED Tags  added in places where  clin i cal  agreement of SNOMED CT codes ha s  taken place to improve interoperability  

  • Elements decomposed : the data models for clinical concepts have been enhanced to be more structured. Includes:   

  • addition of ‘coded’ and ‘free text’ fields for all coded elements, or   

  • restructuring ( eg ) ‘Patient Address’ to include elements for each line of the address.   

This aligns standards closer to the associated technical specifications and therefore makes them more implementable.   

Under pre-publication review
2021-08-04 18:13:52Sandip KaurRelease: Version 2.0 Personalised care and support plan
Updated 2.0 added personal and professional contacts 
                   - structure of needs, goals and concerns
                  -  structured sections to include terminology
                  -  took out procedures and therapies
                  - added tags for SNOMED CT for About me and structured
Under pre-publication review
2021-05-18 18:30:57Sandip KaurRelease: Version 3.1 Community pharmacy standard
Updated due to feedback from NHS digital on sex and gender and value sets for Medication name and Vaccine product
Under pre-publication review
2021-05-05 16:26:15Sandip KaurRelease: Version 3.0 Transfers of care
Final draft of transfers of care standards, pre endorsement.

Maintenance release 2 of the transfer of care standards version 3. 

Updates to align with more structured sections and updated terminology and classifications. 

Also NHS digitals three year standard review as part of the support contract.
Under pre-publication review
2021-04-26 13:45:58Sandip KaurRelease: Version 1.4 Personalised care and support plan
Issues updated with performing professional and person completing record
Under pre-publication review
2021-04-21 13:57:55Sandip KaurRelease: Version 1.2 Urgent transfer from care home to hospital
Name change to urgent transfer from care home to hospital
Under pre-publication review
2021-04-21 13:02:58Sandip KaurRelease: Version 1.2
Updated after Sam's comments 
Under pre-publication review
2021-04-12 16:34:15Sandip KaurRelease: Version 1.3 Personalised care and support plan
Updates to personalised care and support plan from community mental health project 
Under pre-publication review
2021-04-12 12:26:08Sandip KaurRelease: Version 1.1 Local authority information
Updated version after observations for website viewer
Under pre-publication review
2021-04-12 11:08:49Sandip KaurRelease: Version 1.1 Urgent referral and Hospital referral
Updated version after observation update for website viewer
Under pre-publication review
2021-04-09 18:21:51Sandip KaurRelease: Version 1.1 About me and Care home information
Updated version after updates and finalisation for website viewer
Under pre-publication review
2021-04-09 17:07:37Sandip KaurRelease: Version 2.0 Community pharmacy standard
Version 2 of the consolidated community pharmacy standard
Under pre-publication review
2021-03-07 23:56:39Sandip KaurRelease: Version 1.0 Health and care integration standards
Updated terminology and classification mappings and proceeded with endorsement
Under pre-publication review
2020-11-23 16:39:43Sandip Kaur
Version 1.1 Community pharmacy standard - consolidation and review
Under pre-publication review
2020-11-16 18:55:24Sandip KaurRelease: Version 0.4 Health and care integration standards
Draft models for the health and care integration programme
Under pre-publication review
2019-07-18 15:27:45Sandip Kaur
Version 1a - publication of the core information standard
Under pre-publication review
2019-07-11 12:44:58Sandip Kaur
Version 1 - publication of the core information standard.
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