111 Referral Standard: Guidance For All Prsb Standards

It is vital for use of the data that all contextual information is maintained and should not be lost on exchange or import of information. For example, if a frailty assessment was undertaken at the care home 2 days before the individual was admitted to hospital it is important that the full context of the information is known (where and when the assessment was done and by whom).

The principle, for PRSB standards, is that for clinical safety and efficacy of communications, the following key contextual data should be shared where specified by the “information type” of the data item in any PRSB standard.:

• Performing Professional – is the person who performed the activity for example conducted the procedure, assessment etc. It has various attributes that are expected to be completed, name, role, specialty, organisation of the professional. If the professional is not known but the organisation and specialty are known they should be included as contextual information. In some situations, the action or event may be performed by the patient or a device. In these situations, a Performing Person or Performing Device may be recorded. Alternatively a more generic “Performer” may be specified with the same content model as “Performing Professional”.

• Location – the place in which the activity took place e.g., observations were made.

• Date - the date on which the activity took place e.g., the assessment was performed. In some instances, this would be start and end dates.

• Author - is the person, device or application that recorded the information and has various attributes; name, role, speciality and organisation and the date the record was completed. This is expected to be automated and linked to audit trail (see section 2.8).

Note that although both ‘Performing professional’ and ‘Author' contain the element ‘speciality’ it is recognised that this only applies to some professionals so only needs to be included where relevant.

The principle applied in the information model is that where it is important (from a professional perspective) to know who undertook the activity and who recorded the activity, an information type of “Event.Record” or “Record” will be included in the model. For every item of information shared it is important that an audit trail is recorded (even if not explicitly stated in the information model). This is set out below. The provenance information model is published on the PRSB website Provenance data – PRSB (theprsb.org)