111 Referral Standard: Guidance For All Prsb Standards
2.1 Structure of the PRSB standards explained
An information standard is organised into sections made up of several data (information) elements, with record entries and clusters (subsections) to support repeated sets of information and grouping of related items.
The set of rules and instructions governing the type of information expected within a section, cluster, record entry and element and how it is communicated is defined in the information model under the titles of Description, Cardinality, Conformance and Valuesets.
The PRSB information model structure and rules are explained in Table 1 and the annotated example below.
| Information Components | Model Description |
|---|---|
| Section | A section groups together all the information related to a specific topic e.g. ‘Medications and medical devices’ and ‘Person demographics’. |
| It is the highest level to logically group data elements that may be independent or related. For example: | |
| - ‘Legal information’ includes a set of independent elements or information items, grouped in a logical section. | |
| - ‘Medications and medical devices’ includes sets of related elements with dependencies between the elements. | |
| Record entry | A record entry within a section is typically used where a set of information is repeated for a particular item, and there can be multiple items. For example, for each medication there is a set of information associated with that medication. Other examples are allergies or adverse reactions and procedures.
A record entry has contextual information associated with it. The data model for the context information is determined by the information type of the record entry. There are two information types used: “Record” and “Event.Record”. For “Record” entries, the provenance data includes the person recording the data, and the time it was recorded. For “Event.Record” entries, details of the performer of the event, the location, and the time the event happened are also included in the provenance data. |
| Cluster | This is a set of elements put together as a group and which relate to each other; e.g. medication course details cluster which is the set of elements describing the course of the medication. |
| Element | The data item.
An element can appear in one or more sections e.g. name, date. |
| Information model rules and instructions | Explanations |
|---|---|
| Description | This is the description of the section, record entry, cluster or element. For an element, it describes the information that the element should contain in as plain English as possible. |
| Cardinality | Each section, record entry, cluster and element will have a statement of cardinality. This clarifies how many entries can be made i.e. zero, one or many entries. The number of records expected and allowed are displayed as: 0…….* = zero to many record entries are allowed 0…….1 = zero to one record entry is allowed 1…….1 = one record is expected 1…….* = one to many records are expected For example, the ‘Medications and medical devices’ section may have zero to many medication item records in it and is displayed as 0…… *. |
| Conformance | Conformance defines what information is ‘mandatory’, ‘required’ or ‘optional’ and applies to sections, record entries, clusters and elements.
The IT system must be developed to handle all the information elements that are defined in the Standard but not all the information is required for every individual record or information transfer.
The following set of rules apply to enable implementers to cater for the end users (senders and receivers) requirements: |
***Mandatory** – the information must be included
***Required** – if it exists, the information must be included
***Optional** – a local decision is made as to whether the information is included
These rules apply at all levels and give the flexibility to allow local clinical or professional decisions on some information that is included, while being clear on what is important information to include. For example, a person subject to a referral may have many assessments, but not all of these will be relevant to the referral. The conformance can be used to allow just relevant assessments to be included. Assessment Section – Required – i.e. its important information you must include if you have it. Record entry level – Optional – allows a local decision on what assessments are included, so only relevant ones are included based on clinical or professional needs. Assessment elements – Conformance set on the normal basis of which elements for an assessment are mandatory, required or optional. NB: It is permitted to upgrade a conformance rule but not to downgrade one. For instance, a section that is classed as optional in the standard can be upgraded to required or mandatory in local implementations. However, one that is classed mandatory or required cannot be downgraded to required or optional. |
| Valuesets | Valuesets describe precisely how the information is recorded in the system and communicated between systems. This is required for interoperability (for information to flow between one IT system and another).
The information can be text, multi-media or in a coded format. If coded it can be constrained to SNOMED CT and specific SNOMED CT reference sets, NHS Data Dictionary values or other code sets. |
In the annotated example shown below for Allergies:
- The standard has a section for ‘Allergies and adverse reactions’, it’s conformance is ‘mandatory’ and the cardinality is ‘1 only’ (or 1…1) i.e. there must be just one allergies section
- It has a record entry to allow for multiple allergies, which is also ‘mandatory’ so with a cardinality of 1 to many (or 1…*). The record entry contains a set of elements, i.e. the set of information for each allergy and there must be at least 1 record entry.
- The record entry also includes a cluster (reaction details cluster), which groups the reaction details together.
- Each element has a description, conformance, cardinality and valueset. e.g. Causative agent, which is mandatory with a cardinality of 1 only (or 1…1) and a valueset with two options, coded value with a constrained set of SNOMED codes (including an option for “No known allergy”) or free text if coded values are not available. Other elements are required in this example. i.e. the set of information for each allergy or adverse reaction must have a causative agent, and where available should have the other information such as reaction details, substance, severity etc.
| Section | Record entry | Description | Conformance | Cardinality | |
| Risks | Allergies and adverse reactions | Details of any risks related to the person. | R | 0 ... 1 | |
| Allergies and adverse reactions record entry | Allergies and adverse reactions | This is a allergies and adverse reactions record entry. There may be 1 to many record entries under this section. | M | 1 ... 1 | |
| Each record entry is made up of a number of elements or data items. | M | 1 ... * | |||
| Causative agent | The agent such as food, drug or substances that has caused or may cause an allergy, intolerance or adverse reaction in this person Or "No known drug allergies or adverse reactions" Or "Information not available" | M | 1 ... 1 | ||
| Coded value | The coded value for causative agent | R | 0 ... 1 | ||
| Free text | Free text field to be used if no code is available | R | 1 ... 1 | Valueset | |
| Reaction details cluster | Details of the reaction. | R | 0 ... 1 | Free text | |
| Date | The date that the reaction was identified. | R | 0 ... 1 | Date and time | |
| Location | Details of where the allergy was identified. | R | 0 ... 1 | ||
| Coded value | The coded value for location. | R | 0 ... 1 | NHS data dictionary : - Organisation data service | |
| Free text | Free text field to be used if no code is available | R | 0 ... 1 | Free text | |
| Substance | The substance, or a class of substances, that is considered to be responsible for the adverse reaction. | R | 0 ... 1 | ||
| Description of reaction | A description of the manifestation of the allergic or adverse reaction experienced by the person. For example, skin rash. | R | 0 ... 1 | ||
| Severity | A description of the severity of the reaction. | R | 0 ... 1 | ||
| Certainty | A description of the certainty that the stated causative agent caused the allergic or adverse reaction. | R | 0 ... 1 | ||
| Comment | Any additional comment or clarification about the adverse reaction. | R | 0 ... 1 | Free text | |
| Type of reaction | The type of reaction experienced by the person (allergic, adverse, intolerance) | R | 0 ... 1 | FHIR value set :- Allergy, Intolerance, Not known | |
| Evidence | Results of investigations that confirmed the certainty of the diagnosis. Examples might include results of skin prick allergy tests | R | 0 ... 1 | Free text | |
| 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) | R | 0 ... 1 | Date and time | |
| Probability of recurrence | Probability of the reaction (allergic, adverse, intolerant) occurring. | R | 0 ... 1 | Free text | |
| Performing professional | The professional who identified the reaction. | R | 0 ... 1 | ||
| Person completing record | Details of the person completing the record. | R | 0 ... 1 | ||
| Medications and medical devices | Medications and medical devices | R | 0 ... 1 |
Page last updated: 06 January 2026