Conceptual Model

Introduction to the MODS

FHIR Profiles

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

Guidance for CQC registered adult social care providers and their associated suppliers implementing the Adult Social Care Record (MODS) which represents the minimum operational data standard for direct care data in England.

## Purpose

This document is designed to serve as a comprehensive guide for the implementation of the Adult Social Care Record - Minimum Operational Data Standard (MODS). It aims to detail the updates and modifications in the latest release, ensuring that stakeholders are informed about the essential classes of data encompassed within this standard and the dependencies between it and other standards.. The primary intent is to facilitate a smooth adoption and practical application of a standardised data specification across organisations involved in adult social care.

The guidance provided here should be considered in conjunction with the [specific data dictionary for MODS that can be found here]() and the overarching Conceptual Model for Adult Social Care that can be found here. These resources collectively form a robust framework for understanding and applying the data standard effectively.

 ### Aims and objectives of the Adult Social Care Record (MODS)

The primary objective of the Adult Social Care Record (MODS) is to establish a minimum data requirement for direct care data by CQC registered adult social care providers and the suppliers. Establishment of the Adult Social Care Record (MODS) aims to create:

**Consistent Data Collection:** Establish a uniform baseline for data gathering by CQC registered adult social care providers, aiming to enhance the quality of care delivered.

**Standardised Data Formats:** Promote the use of consistent data structures, acting as a 'common glue' to enable safe data sharing and more cohesive care delivery across different entities.

**Regulatory Compliance and Best Practices:** Reflect regulatory demands and disseminate best practices for data management within the sector.

**Reduction of Administrative Burden:** Minimise repetitive data entry and overlapping reporting obligations, thereby streamlining operational processes.

**Alignment with Broader Standards:** Synchronise with existing standards in the wider health and social care systems to avoid inefficiency and redundant efforts ‘reinventing the wheel’.

**Specialised Data Model:** Develop a data model that integrates with current healthcare frameworks but is specifically tailored to the needs of social care.

**Support for Technological Advancements:** Foster innovation and the integration of assistive technology within the care sector.

 ### Target Audience

The MODS is primarily developed for care providers and suppliers of information systems in the adult social care sector. This guidance is particularly beneficial for those involved in implementing digital systems in care settings, including integration across various providers. It also serves as a vital resource for care professionals responsible for submitting data into systems using the MODS framework.

Furthermore, MODS is relevant to a diverse range of stakeholders, as outlined in the identified 
Personas, ensuring a comprehensive understanding and application of the data standard across the sector.

## Background 
The Adult Social Care Record (MODS) is designed to establish a suite of interoperable components that, when combined, create a comprehensive digital record for adult social care. These components, or "building blocks," are versatile and can be assembled into specific configurations or included within particular forms, yet they are all unified under an extensive conceptual framework. For instance, an identified need—a fundamental element of the digital social care record—is always connected to an individual. This need might be recognised during various interactions, such as in the process of assessment, within care planning, or through the actual delivery of care services.

**Latest Version:**

Version 0.2.0 marks the latest iteration of the Adult Social Care Record (MODS) beta. This iteration is the culmination of an initial discovery phase and the creation of an alpha version of MODS. The ongoing beta phase, along with the forthcoming stages of development, are dedicated to refining the functionality of MODS to ensure optimal performance. The development team is actively engaged in soliciting and incorporating user feedback, with the goal of continuously enhancing MODS in alignment with the insights gained from practical use and research.

 

### Our Approach

**Related Standards and Programmes of Work:**

<ul>
  <li><a href="https://gpitbjss.atlassian.net/wiki/spaces/DSCR/overview?homepageId=11971330147">Digital Social Care Record (DSCR)</a></li>
  <li><a href="http://www.en13606.org/information.html">ISO 13606</a></li>
  <li><a href="https://contsys.org/page/default">Contsys</a></li>
  <li><a href="https://theprsb.org/core-information-standard-v2-0/">PRSB Core Information Standard</a></li>
  <li><a href="https://simplifier.net/hl7fhirukcorer4">HL7 FHIR UK CORE</a></li>
  <li><a href="https://termbrowser.nhs.uk/?">SNOMED CT (UK Edition)</a></li>
  <li><a href="https://www.datadictionary.nhs.uk/">NHS Data Dictionary</a></li>
  <li><a href="https://digital.nhs.uk/data-and-information/information-standards/information-standards-and-data-collections-including-extractions/publications-and-notifications/information-standards-notices">ISN Approved Collections</a></li>
  <li><a href="https://openreferraluk.org/">Open Referral</a></li>
  <li><a href="https://standards.esd.org.uk/?">LGA inform</a></li>
  <li><a href="https://coda.io/@savvi/welcome/the-savvi-concept-model-21">SAVVI</a></li>
  <li><a href="https://ckm.openehr.org/ckm/projects/1013.30.77">OpenEHR Social Determinants of Health</a></li>
  <li><a href="https://ckm.openehr.org/ckm/projects/1013.30.39">OpenEHR Social Context Project</a></li>
  <li><a href="https://confluence.hl7.org/display/GRAV/The+Gravity+Project">The Gravity Project - Gravity Project - Confluence</a></li>
  <li><a href="https://confluence.ihtsdotools.org/display/SCCDP/Social+care+content+requirements+project?src=sidebar">SNOMED International Social Care Project</a></li>
</ul>
 

**ISO13606:**

“ISO 13606 is a standard from the International Standardization Organization (ISO), originally designed by the European Committee for Standardization (CEN).

The overall objective of the ISO 13606 standard is to define a rigorous and stable information architecture for communicating part or all of the electronic health record (EHR) of a single subject of care (patient) between EHR systems, or between EHR systems and a centralized EHR data repository. It may also be used for EHR communication between an EHR system and clinical applications or middleware components (such as decision support components) that need to access EHR data, or as the representation of EHR data within a distributed (federated) record system.”

 

Classes of information about the person within the MODS will fall into one of the following categories:

<p>///mermaid
graph TD
accTitle: Classes of information about the person within the MODS will fall into one of the following categories
    accDescr: Imagine a giant digital folder that holds all of a person’s health information in one place. Inside this folder, information is organized a bit like a nesting doll: big folders contain individual records (like a doctor's visit note), and those notes are broken down into smaller sections and specific entries. Each entry then points to the tiny details, such as a specific test result or a single measurement. The system is designed to handle general details about who the person is alongside these specific health stories, making sure that every piece of information—from a broad summary to a single data point—stays connected and easy for healthcare staff to find.
    subgraph EHR_EXTRACT
        DEMOGRAPHIC_DATA[DEMOGRAPHIC DATA]

        FOLDER[FOLDER] --&gt;|sub_folders| FOLDER
        FOLDER -.-&gt;|compositions| COMPOSITION[COMPOSITION]
        
        COMPOSITION --&gt;|content| SECTION[SECTION]
        COMPOSITION --&gt;|content| ENTRY[ENTRY]
        
        SECTION --&gt;|members| SECTION
        SECTION --&gt;|members| ENTRY
        
        ENTRY --&gt;|items| CLUSTER[CLUSTER]
        ENTRY --&gt;|items| ELEMENT[ELEMENT]
        
        CLUSTER --&gt;|parts| CLUSTER
        CLUSTER --&gt;|parts| ELEMENT
        
        ELEMENT --&gt;|value| DATA_VALUE[DATA_VALUE]
    end
</p>
<ul class="details">
<li><a href="">Explain the Classes of information about the person within the MODS diagram</a>
<div>Imagine a giant digital folder that holds all of a person’s health information in one place. Inside this folder, information is organized a bit like a nesting doll: big folders contain individual records (like a doctor's visit note), and those notes are broken down into smaller sections and specific entries. Each entry then points to the tiny details, such as a specific test result or a single measurement. The system is designed to handle general details about who the person is alongside these specific health stories, making sure that every piece of information—from a broad summary to a single data point—stays connected and easy for healthcare staff to find.</div>
</li>
</ul>


**EHR_EXTRACT:** The top-level container of part or all of the health and adult social care record of a single subject of care, for communication between an EHR Provider system and an EHR Recipient. 
**FOLDER:** The high level organisation within a health and adult social care record, dividing it into compartments relating to care provided for a single condition, by a clinical team or institution, or over a fixed time period such as an episode of care. Examples of FOLDER are Diabetes care, Schizophrenia, Cholecystectomy, Paediatrics, St Mungo’s Hospital, GP Folder, Episodes 2000-2001, Italy. 
**COMPOSITION:** The set of information committed to one health and adult social care record as a result of a clinical encounter or a record documentation session. Examples of COMPOSITION are Progress note, Laboratory test result form, Radiology report, Referral letter, Clinic visit, Clinic letter, Discharge summary, Functional health assessment, Diabetes review. 
**SECTION:** EHR data within a COMPOSITION that belongs under one care heading, usually reflecting the flow of information gathering during a care encounter, or structured for the benefit of future human readership. Examples of SECTION are Reason for encounter, Past history, Family History, Allergy information, Subjective symptoms, Objective findings, Analysis, Plan, Treatment, Diet, Posture, Abdominal examination, Retinal examination. 
**ENTRY:** The information recorded in a health and adult social care record as a result of one clinical action, one observation, one clinical interpretation, or an intention. This is also known as a clinical statement. Examples of ENTRY are a symptom, an observation, one test result, a prescribed drug, an allergy reaction, a diagnosis, a differential diagnosis, a differential white cell count, blood pressure measurement. 
**CLUSTER:** The means of organising nested multi-part data structures such as time series, list or tables. Examples of CLUSTER are Audiogram results, electro-encephalogram interpretation, weighted differential diagnoses. 
**ELEMENT:** The leaf node of the health and adult social care record hierarchy, containing a single data value. Each ELEMENT contains data of a particular Data Type. Examples of ELEMENT are Systolic blood pressure, heart rate, drug name, symptom, body weight.
 

For more information on that standards please see 
[ISO 13606 Standard - EHR Interoperability](http://www.en13606.org/information.html)

## Requirements and use Cases

The NHS Transformation Directorate's Digitising Social Care (DiSC) Programme has introduced an Assured Supplier List to support Adult Social Care providers in England in selecting from a verified roster of Digital Social Care Records (DSCR) Solutions. These solutions have been integrated through the Dynamic Purchasing System (DPS), with its specifications transformed into Capabilities and Standards to align with the Digital Care Services (DCS) Framework.

The Adult Social Care Record (MODS) is a critical component of these data standards. It encompasses data classes and data elements that outline the requirements for how information should be recorded from individuals receiving care from a CQC regulated social care service.

In the process of establishing the MODS, a series of use cases and requirements were identified:

*[Use case 1: Consistency of care to an individual when a temporary worker needs to step in]()
*[Use case 2: Communicating an individual's care needs between local authority and care provider at the point of commissioning]()
*[Use case 3: Consistency of care and recording across a multi-disciplinary team]()
*[Use case 4: Providing consistent support in hospital and at home for an individual with an existing care plan]()
*[Use case 5: Implementing a new social care system]()
*[Use case 6: Care provider moving to a digital system]()
*[Use case 7: Sharing elements of care planning information across many systems – components or "building blocks" of care plan]()
*[Use case 8: DHSC receiving information from local authorities and care providers]()
*[Personas]()
*[Additional use cases]()

### Use case 1: Consistency of care to an individual when a temporary worker needs to step in

### Use case 2: Communicating an individual's care needs between local authority and care provider at the point of commissioning

### Use case 3: Consistency of care and recording across a multi-disciplinary team

An individual's daily care involves a diverse group of healthcare and social care practitioners—including GPs, district nurses, social workers, care providers, care workers, social prescribers, local authority call handlers, among others. While these care workers do not function as a unified multi-disciplinary team, they require access to comprehensible and precise records. These records must be articulated in a vernacular that merges clinical precision with everyday language, enabling these varied practitioners to document and exchange information effectively. This collaborative approach is essential to inform continued care and support the individual in leading their desired lifestyle.

### Use case 4: Providing consistent support in hospital and at home for an individual with an existing care plan

Teams responsible for hospital admissions and discharges understand the existing care plans and ensure that they communicate the requisite care details to care providers upon a patient's discharge.

### Use case 5: Implementing a new social care system

Enabling easier implementation of new adult social care IT systems

### Use case 6: Care provider moving to a digital system

As care providers move to digital systems by 2025, this will enable easier transfer of routine info to local authorities

### Use case 7: Sharing elements of care planning information across many systems – components or "building blocks" of care plan

This use case does not follow the structure of the others, as there are multiple scenarios involved. Instead we have identified a range of user needs which combine to describe the benefits of a properly structured record.

### Use case 8: DHSC receiving information from local authorities and care providers

#### Use case:
DHSC able to receive management information from all local authorities and adult social care providers which uses agreed, understood and shared terminology

#### Scenario:
*The Department of Health and Social Care (DHSC) are working to improve the way they collect management information from local authorities and adult social care providers. They have noticed that the information they are receiving is often inconsistent and during sessions to analyse the data with local authorities and adult social care providers they discussed the data discrepancies. This highlighted different understanding of the terms being used differently by local authorities and adult social care providers, for example 'carer' and other terms like 'personal budget' and ‘needs assessment’ had varying definitions.
*A glossary of adult social care terminology with agreed definitions would help to resolve this issue and provide more consistent data for both health and adult social care, supporting improved secure information sharing available at the right time for the right person in the right place for direct care.

#### Goal: 
DHSC receive management information in a consistent format with agreed and understood terminology to ensure information is reported consistently. To do this, an agreed glossary of terms and definitions should be created in partnership with health, care providers and local authorities.

#### Assumptions: 
Throughout the discovery phase of this project we have identified a number of words/terms that are used inconsistently by different services or have multiple meanings. Finding consistent definitions can be difficult and often each authority has a slightly different definitions for a term, a good example is personal budget. Having a defined and consistent terminology that all local authorities and care providers use would reduce the confusion and inconsistency.

### Personas

During development of the minimum operational data standard the following stakeholder groups were identified:

Health and adult social care professional bodies
Local Government Association - Adult Social Care
Adult Social Care CQC registered and non-registered providers
NHS - primary, secondary and community care
NHS England/Improvement, NHS Digital, DHSC
Local Government - other
Other central government departments/agencies/NDPBs
System suppliers
Individuals and their representative bodies (inc voluntary sector)
Academia, research, statistics
Other professional stakeholders
Technology Enabled Care
Professional Bodies e.g. PRSB
CQC Registered Manager
Deputy Home Manager/Care Manager /Deputy Care Manager/Senior Carer/Team Leader
Pharmacist/ Pharmacy technician
Nurses (currently can access full record if needed)
Social workers
Care workers - paid or unpaid

195 organisations were engaged, either through webinars or meetings. A diverse mix or roles were identified across the attendees from each organisations and several themes emerged. Personas were developed where the people engaged had similar roles and a similar set requirements.

The focus of the development of the personas for the MODS was to identify end-users of the minimum operational dataset product as a standard i.e. the people who would understand the data specifications, rather than the ultimate end users of the data. These include:

Performance Manager
Data Architect
Business Intelligence Manager
Software Developer
Business Analyst
Business Lead
Systems Integrator
Individuals and care workers who will be end-users of the data have been represented during the development of the MODS by DSCR assured solution suppliers, professional bodies and many others listed. However, these users, whilst they do consume and collect data through digital systems build to a specification consistent with the MODS, may not be the users who will be reading the detail of and be configuring systems to capture the MODS formats as part of of their core role, therefore they have not been included in this set of personas.

The following personas and uses of the MODS standard as a product have been identified below:

### Additional use cases

Additional use cases, prioritised and mapped to care actors:

<table>
<thead>
<tr>
<th>Category</th>
<th>Use case</th>
<th>Priority (derived from stakeholder survey)</th>
<th>LA ASC</th>
<th>Care recipients</th>
<th>Carers</th>
<th>Care providers</th>
<th>NHS</th>
<th>PH</th>
<th>C&amp;F</th>
<th>DHSC</th>
<th>Software suppliers</th>
</tr>
</thead>
<tbody>
<tr>
<td>Individual</td>
<td>Multiple clinicians/professionals/carers involved in an individual's day-to-day life (GP, District Nurse, social worker, care provider, care worker, social prescriber, local authority call handler, others), not operating as part of a multi-disciplinary team, but needing to access clear and accurate records - in a language that bridges the gap between clinical and everyday terminology - and capture/share information to inform ongoing care delivery and to help the person live the life they want to.</td>
<td>3.97</td>
<td>Y</td>
<td>Y</td>
<td>Y</td>
<td>Y</td>
<td>Y</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr>
<td>Individual</td>
<td>Communicating an individual's care needs between local authority and care provider at the point of commissioning</td>
<td>3.86</td>
<td>Y</td>
<td>Y</td>
<td></td>
<td>Y</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr>
<td>Individual</td>
<td>Hospital admissions/discharge teams understand the care plan already in place and are able to provide the necessary care information to care providers on discharge</td>
<td>3.86</td>
<td>Y</td>
<td>Y</td>
<td>Y</td>
<td>Y</td>
<td>Y</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr>
<td>Individual</td>
<td>Consistency of care to an individual when a temporary worker needs to step in</td>
<td>3.79</td>
<td></td>
<td>Y</td>
<td>Y</td>
<td>Y</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr>
<td>Individual</td>
<td>Care Home sending information to GP system</td>
<td>3.21</td>
<td></td>
<td>Y</td>
<td></td>
<td>Y</td>
<td>Y</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr>
<td>Service</td>
<td>Enabling easier implementation of new social care IT systems</td>
<td>4.00</td>
<td>Y</td>
<td></td>
<td></td>
<td>Y</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>Y</td>
</tr>
<tr>
<td>Service</td>
<td>Sharing elements of care planning information across many systems – componentisation of care plan</td>
<td>3.90</td>
<td>Y</td>
<td></td>
<td></td>
<td>Y</td>
<td>Y</td>
<td>Y</td>
<td></td>
<td></td>
<td></td>
</tr>
<tr>
<td>Service</td>
<td>As care providers move to digital systems (by 2024?), enable easier transfer of routine info to local authorities</td>
<td>3.79</td>
<td>Y</td>
<td></td>
<td></td>
<td>Y</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>Y</td>
</tr>
<tr>
<td>Service</td>
<td>DHSC able to receive management information from all local authorities and care providers which uses agreed, understood and shared terminology</td>
<td>3.76</td>
<td>Y</td>
<td></td>
<td></td>
<td>Y</td>
<td></td>
<td></td>
<td></td>
<td>Y</td>
<td></td>
</tr>
<tr>
<td>Service</td>
<td>Population Health Management – greater ability to share health and care datasets to gain insights across a place</td>
<td>3.41</td>
<td>Y</td>
<td></td>
<td></td>
<td>Y</td>
<td>Y</td>
<td>Y</td>
<td></td>
<td>Y</td>
<td></td>
</tr>
<tr>
<td>Service</td>
<td>Care providers can interrogate the data they are capturing, rather than just recording it</td>
<td>3.41</td>
<td></td>
<td></td>
<td></td>
<td>Y</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr>
<td>Service</td>
<td>Local authorities receiving information from care providers that enables activity (review of needs etc) to be stratified through artificial intelligence</td>
<td>3.17</td>
<td>Y</td>
<td></td>
<td></td>
<td>Y</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
</tbody>
</table>

## Information Governance

Information Governance is a key aspect of the Authority's requirements for all assured solution systems suppliers under the DiSC Framework and contract agreements for the standards and capabilities who record considerable amounts of sensitive, personally identifiable information, this Standard intends to provide controls over the processing and use of that data. They must comply with these principles. For more information please visit [Information Governance (DSCR)](https://gpitbjss.atlassian.net/wiki/spaces/DSCR/pages/12238684246/Information+Governance+DSCR)
  
Care actors recording the MODS data in digital systems, must comply with the following principles specific to adult social care in the [Care Quality Commission Regulation: 17 Good governance](https://www.cqc.org.uk/guidance-providers/regulations-enforcement/regulation-17-good-governance) and the [Care Quality Commission Code of practice on confidential personal information](https://www.cqc.org.uk/sites/default/files/20180419%20Code%20of%20practice%20on%20CPI%20with%20GDPR%20and%20IRMER%20updates.pdf)

## Accessible Information Standard

From 1 August 2016 onwards, all organisations that provide NHS care and/or publicly-funded adult social care are legally required to follow the **Accessible Information Standard**:

“The Accessible Information Standard aims to make sure that people who have a disability, impairment or sensory loss get information that they can access and understand, and any communication support that they need from health and adult social care services.”

Adult social care providers and assured solution suppliers implementing the MODS should allow “patients, service users, carers and parents with a disability, impairment or sensory loss to:

Be able to contact, and be contacted by, services in accessible ways, for example via email or text message.
Receive information and correspondence in formats they can read and understand, for example in audio, braille, easy or large print.
Be supported by a communication professional at appointments if this is needed to support conversation, for example a British Sign Language interpreter.
Get support from health and care staff and organisations to communicate, for example to lip-read or use a hearing aid.”
[More information on the standard is available here](https://standards.nhs.uk/published-standards/accessible-information)

## Audit and provenance information

All information recorded must include audit information about when a record was created, modified, completed and authorised and by whom. This may also include proof of an attestation i.e. authorisation and the source system where the information was recorded.

Audit information is about the provenance of information record itself rather than information about who performed an activity.

[For more information about audit and provenance see the audit and provenance conceptual model.]()

## Conceptual Model: Adult Social Care Record

Version: 0.2.1 Beta

Release date: 12.02.2024

Abstract: A visualisation of a conceptual data model for adult social care based on the International Standard EN ISO 13940:2016 and Contsys:2019

Keywords: Adult Social Care, Care Actor, Assessment, Care Plan, Instruction, Activity, Action, Administrative, Consent, Legal, Audit, Provenance, Conceptual Model, Adult Social Care Record, MODS, Minimum Operational Dataset, Data Standard

Contact Point: 
External Link Content Image
Jira Service Management

Overview:
<p>///mermaid
graph TD
 accTitle: A visualisation of a conceptual data model for adult social care based on the International Standard EN ISO 13940:2016 and Contsys:2019
    accDescr: This diagram shows how different people and groups work together to support someone who needs care. At the heart of it all is the person being looked after, surrounded by the important details that keep them safe, such as their legal rights and their permission for care. A team of professionals—which could be an individual, a small team, or a large organization—uses this information to provide support and make decisions on the person's behalf. By carefully watching and recording what they see (observations), these helpers can figure out the best way to plan the person's care and daily activities. These observations act as a guide: they tell the team what is happening right now and help them decide which actions or plans are needed to help the person live their best life.

    Audit[Audit Info.]

    Org[Organisation] --- CareActors[Care Actors]
    Team[Team] --- CareActors
    Person[Person] --- CareActors

    CareActors ---|Supports<br>Provides Care for<br>Takes Decisions on Behalf of| Subject[Subject of Care]

    Legal[Legal Information] ---|Concerns| Subject
    Admin[Administrative Information] ---|Concerns| Subject
    Consent[Consent Information] ---|Concerns| Subject

    Subject ---|Performed for| Assessments[Assessments]
    Subject ---|Performed for| Plans[Care Plans]
    Subject ---|Performed for| Actions[Instructions<br>Actions<br>Activities]

    Subject ---|Refers to| Obs[Observations]
    
    Obs ---|Recorded| Assessments
    Obs ---|Recorded| Plans
    Obs ---|Recorded| Actions
    
    Obs ---|Influences| Assessments
    Obs ---|Influences| Plans
    Obs ---|Influences| Actions
</p>

<ul class="details">
<li><a href="">Explain the visualisation of a conceptual data model for adult social care based on the International Standard EN ISO 13940:2016 and Contsys:2019</a>
<div>This diagram shows how different people and groups work together to support someone who needs care. At the heart of it all is the person being looked after, surrounded by the important details that keep them safe, such as their legal rights and their permission for care. A team of professionals—which could be an individual, a small team, or a large organization—uses this information to provide support and make decisions on the person's behalf. By carefully watching and recording what they see (observations), these helpers can figure out the best way to plan the person's care and daily activities. These observations act as a guide: they tell the team what is happening right now and help them decide which actions or plans are needed to help the person live their best life.</div>
</li>
</ul>


Care actor
s include People, Teams and Organisations who can have multiple roles where they Support, Provide Care for and/or Take decisions on behalf of the Subject of Care

Assessment
s &amp; 
Care plan
s are performed for the Subject of Care and can be influenced by 
Observation
s about the Subject of Care. These result in 
Instruction, activity &amp; action
s which may result in further 
Observation
s being recorded which in turn may trigger Re
Assessment
s &amp; 
Care plan
 reviews.

Consent and legal information
 concerning the subject of care must be captured to inform the provision of care, as well as 
Administrative Information
 that will inform operational delivery of care.

All adult social care records must include
Audit Information
 information.

### Care actor

Organisation, team or person participating in health and adult social care.

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

#### Care plan

A written plan typically recorded after an assessment, addressing the needs and risks associated with the person receiving care and setting out goals and instructions for the care they will receive. The person receiving care should have the opportunity to be fully involved in the plan and to say what their priorities are. If the person receiving care is in a care home, home care (domiciliary care), or attends a day service, the plan for their daily care may also be called a care plan.

#### Instruction, activity &amp; action

Records of instructions, activities and actions detail how care should be, and how care has been, provided. Instructions target goals from the care plan and determine a set of planned Activities. Actions log that a planned (or unplanned) activity has been completed and any associated outcomes or observations.

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

#### Administrative Information

Information recorded when a person interacts with health and adult social care actors and concerning the management of a person's care and those responsible for caring for them.

#### Consent and legal information

Records of informed consent and legal information for a person’s care.

#### Audit Information

Information about the provenance of all information recorded and any changes to an information record for audit purposes:

## Data Dictionary: Overview

The Minimum Operational Data Set impacts CQC registered adult social care providers and the suppliers of their respective Digital Social Care Records.

MODS release 0.2.1 is a minimum viable product and as such, is an initial data specification that will form the basis of a national social care information standard that covers provider activity and the information needed to support the deliver of care. It provides a ‘blueprint’ for the classes of data and formats for data that a provider should support.

What it is not: MODS is not a national data collection and does not imply that a care provider must capture all of the content in the model.

The Minimum Operational Dataset includes the following classes of data:

Care actors are organisations or persons participating in health and adult social care. The following care actors are included in the MODS:

Care Organisation
Care Provider : information about a care provider supporting the subject of care. Includes Healthcare services, Community or Integrated healthcare, Residential Social Care, Community Social Care and Other Health and Adult Social Care Services.
GP Practice: information about the subject of care’s registered GP practice.
Local Authority: information about the local authority that a care actor is an ordinary resident in e.g. place where you live, or main home, which determines which council will assess your needs and potentially fund any care and support you need. If you have more than one home, councils follow guidance from the Government to help them decide which one is your main home, and which council should fund your care.
Care Worker:
Care Worker: details of the person’s professional contacts including other regulated care providers.
GP: details of the person’s general practitioner.
Local authority professional: details of professional working for the local authority to support the subject of care.
Subject of Care: A person who seeks to receive, is receiving, or has received care.
Proxy for Subject of Care: Health and adult social care third party having person role with the right to take decisions on behalf of the subject of care. One or more people can be given power (Lasting Power of Attorney) by the person when they had capacity to make decisions about their health and 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.
Unpaid Carer: Information about somebody who provides support or who looks after a family member, partner or friend who needs help because of their age, physical or mental illness, or disability. This would not usually include someone paid or employed to carry out that role, or someone who is a volunteer.
Personal Contact: The details of the subject of care’s personal contacts and information about the relationship between the subject of care and the person.
See the Care actor conceptual model for a visualisation of care actors and the relationships between them.

Assessments include social care assessments of needs, risks, mental capacity, wishes, preferences, strengths and finances.

Care Needs Assessment: Local authorities must carry out an assessment of anyone who appears to require care and support. The aim of assessment is to understand the person's needs and goals. Providers additionally assess and review needs, risks and mental capacity, as well as collect background “about me” information. N.B. results from specific assessments i.e. Waterlow, would be recorded as an observation and be considered as part of the assessment and care planning process.
Risk Assessment: An assessment of your health, safety, wellbeing and ability to manage your essential daily routines. You might also hear the term risk enablement, which means finding a way of managing any risks effectively so that you can still do the things you want to do.
Mental Capacity Assessment [PRSB]: Mental capacity needs to be assessed at each decision point, for instance where decisions around treatment, discharge, support needs, living situation or other factors need to be made. Hence there should be provisions for more than one mental capacity assessment to be shared. If sharing the outcome of a mental capacity assessment it is important to record to which decision it relates. The mental capacity assessment is based on one of the following Acts, Mental Capacity Act 2005 (England and Wales) Adults with Incapacity Act 2000 (Scotland) Mental Capacity Act 2016 (Northern Ireland).
About me [PRSB]: About Me information is the detail that a person wants to share with professionals in health and adult social care in a narrative form.
Note: Results from specific assessments e.g. Waterlow, MUST, Bedrail, Abbey Pain, would be recorded as Observations and the results would be considered as part of the Risk or Care Need Assessments.

See the Assessment conceptual model for a visualisation of assessment entries and the relationships between them.

Care Plans are written plans, after you have had an assessment, setting out what your care and support needs are, how they will be met (including what you or anyone who cares for you will do) and what services you will receive. The subject of care should have the opportunity to be fully involved in the plan and to say what their priorities are. If they are in a care home or attend a day service, the plan for their daily care may also be called a care plan.

Care and support plan [PRSB]: This records the decisions reached during conversation between the individual and health and care professional about future plans and also records progress.
Additional support plans [PRSB]: Additional care and support plan which the person and/or care professional consider should be shared with others providing care and support.
Contingency plan [PRSB]: These are the things to do and people to contact, should an individual’s health or other circumstances get worse.
End of life care plan: Details of a person's palliative and end of life care plans. Based on the PRSB end of life care plan.
See the Care plan conceptual model for a visualisation of care plan entries and the relationships between them.

Instructions, Activities &amp; Actions. Instructions include a summary of how care should be provided. Instructions contain multiple activities. Activities are actionable records linked to an instruction that are planned or scheduled to take place. Actions are usually logged against each Activity but can also be ad-hoc to record that an action has been performed.

Note: The model is based on the 
External Link Content Image
EHR Information Model
:



Instruction: Information, including a narrative summary, describing how care should be delivered based on a care plan(s). Usually linked to a set of specific activities.
Activity: Defines an actionable activity , such as a medication administration.
Medication [PRSB]: All medications and devices that can be prescribed to be entered via this Medication item entry. Handles details of continuation / addition / amendment of admission medications.
Vaccination [PRSB]: Details of vaccinations.
Procedure [PRSB]: The details of any procedures performed. Includes both psychological and medical therapies and procedures (e.g. cognitive behaviour therapy, hip replacement).
Communication: A record of a communication e.g. planned, completed, failed etc.
Task: A record of a specific actionable activity that can be preformed to support the subject of care (e.g. household task).
Referral [PRSB]: Used to record and send details about a request for referral service or transfer of a patient to the care of another provider or provider organisation.
Service: Used to record services delivered as part of a person’s care plan
Device: Used to record provision of assistive technology, equipment and medical devices
Transfer of care: When you move from one place of care to another, such as from hospital to your home, supported housing or residential care. Your transfer should be properly planned and coordinated, and health and social care services should work together. Transfers of care may be delayed for various reasons. For example, you may be ready to leave hospital but end up staying there longer than you need to, while you wait for community care services or a place in a care home to be available.
Action: Used to record an action that has been performed, which may have been ad hoc, or due to the execution of an Activity in an Instruction workflow. Note: actions may or may not be part of a single document and can be recorded and associated with an activity once the action has been completed.
See the Instruction, activity &amp; action conceptual model for a visualisation of entries and the relationships between them.

Observations:

Alerts [PRSB]: Details of an alert, which should be determined locally. They might, for example, include the fact that the person has a dangerous dog. It is important that alerts are managed and removed when they are no longer relevant - e.g. 'the dangerous dog' alert if the dog is no longer present. The alerts displayed to users viewing the core information may vary by use case and user's role.
Allergies and adverse reactions [PRSB]: Details about the Subject of care's allergies or adverse reactions.
Circumstances: Used to record observed circumstances that impact a person’s health and wellbeing.
Access requirements [PRSB]: Details of access for the person, such as special access requirements
Accommodation status [PRSB]: Details of the type of accommodation where the person lives.
Dependants: Details of any dependants
Education history [PRSB]: The current and/or previous relevant educational history of the person.
Household composition [PRSB]: Description of the household composition e.g. lives alone, lives with family, lives with partner, etc.
Household environment [PRSB]: Factors in the household which impact the person's health and wellbeing, to include smoking in the home, alcohol/substance use etc.
Occupational history [PRSB]: The current and/or previous occupation(s) of the person
Social Circumstances [PRSB]: Details of the persons social circumstances
Environment: Factors in a persons environment that could impact the person's health and wellbeing or are relevant to actors providing care e.g. near a busy road or where a stopcock is located outside a property
Daily living: Observation of activities relating to personal care and mobility about the home that are basic to daily living.
Goal: The overall goals, hopes, aims or targets that the person has. Including anything that the person wants to achieve that relates to their future health and wellbeing. Each goal may include a description of why it is important to the person. Goals may also be ranked in order of importance or priority to the person.
Incident: An incident that occurred in relation to care services resulting in unexpected or avoidable death, harm or injury to patient, carer, staff or visitor.
Investigation results [PRSB]: Healthcare activity with the intention to clarify one or more health conditions of a subject of care. This can include a report which may have results for multiple tests.
Outcome: End result, change or benefit for an individual who uses social care and support services.
Need: All needs, including emotional, social, cultural, religious and spiritual needs, should be included in assessments about the care and treatment people receive.
Preferences: A description of what is most important to a person, the people who are important to a person and things a person wants someone supporting them to do or not to do.
Problem [PRSB]: Healthcare problems associated with the Subject of care.
Risk: Details about a risk to a person or others, this includes any risk the person might cause to them self or to others. e.g. suicide, self harm
Safeguarding concerns [PRSB]: Identified safeguarding concerns protecting vulnerable people from neglect or physical, financial, psychological, verbal or other forms of abuse. Implementation guidance: It is recognised that local authorities may not record the details of safeguarding concerns as a matter of policy. In such scenarios, health and social care organisations enquiring about a safeguarding flag may be directed to the local Multi-Agency Safeguarding Hub (MASH) team.
Strengths [PRSB]: A description of strengths and assets the person has relating to their goals and hopes about their health and well-being.
Wishes: A record of a person's aspirations and a description of things they want someone supporting them to do (or not to do)
See the Observation conceptual model for a visualisation of entries and the relationships between them

 

Administrative Information: Information recorded when a person interacts with health and adult social care services and concerning the management of a persons care and those responsible for caring for them.

Address: The identification of a place of relevance. This could be to a: PERSON ORGANISATION ORGANISATION_SITE or LOCATION. The ADDRESS may have COMMUNICATION_CONTACT_METHOD associated with it and may be the location for an ACTIVITY.
Admission Details [PRSB]: Details about a health and social care admission.
Communication: A record of a communication or correspondence, including the status such as preparation, completed, stopped etc.
Discharge details [PRSB]: Details about a health and social care setting discharge.
Document [PRSB]:Details about documents related to the person.
Events: Abstract class. Contains information that should be included as part of any event record e.g. plan, assessment, observation etc.
Location: A physical LOCATION. This could be: where a SUBJECT OF CARE is seen where SERVICES exist from which requests for ACTIVITIES are sent or any other place of interest to an ORGANISATION which is not recorded as an ORGANISATION or an ORGANISATION_SITE. For ACTIVITIES provided by staff groups, LOCATIONS are places where a face-to-face contact or a Group_Session occurs. For diagnostic ACTIVITIES, LOCATIONS either define the whereabouts of the ACTIVITY or the places from which requests are sent. Each LOCATION must be classified by one and only one type of LOCATION and the same classification must be used by all users.
Occupancy: Record of occupancy and availability for a given location.
Review [PRSB]: Details of a scheduled re-assessment of a person’s needs and/or review of a care plan, so that people can look at whether the services a person is receiving meet their needs and help them to achieve their goals.
See the Administrative Information Conceptual Model for a visualisation of entries and the relationships between them.

 

Consent and Legal Information: Information recorded about a consent given by a person concerning the management of a persons care and those responsible for caring for them, as well as the legal records relating to a person.

Cardio-pulmonary resuscitation [PRSB]: Whether a decision has been made, the decision, who made the decision, the date of decision, date for review and location of documentation. Where the person or their family member/carer have not been informed of the clinical decision please state the reason why,
Informed consent: The voluntary and continuing permission of the person to receive particular treatment or care and support, based on an adequate knowledge of the purpose, nature, likely effects and risks including the likelihood of success, any alternatives to it and what will happen if the treatment does not go ahead. Permission given under any unfair or undue pressure is not consent. By definition, a person who lacks capacity to consent cannot consent to treatment or care and support, even if they cooperate with the treatment or actively seek it.
Lasting power of attorney [PRSB]: Details of the person's LPA record or equivalent. A legal instrument that allows a person (the 'donor') to appoint one or more people (known as 'attorneys') to make decisions on their behalf. There are 2 types: health and welfare, and property and financial affairs, and either one or both of these can be made. To have legal force, lasting powers of attorney must be created in accordance with section 9 and section 10 of the Mental Capacity Act 2005. The attorney must have regard to section 4 of the Mental Capacity Act 2005, the Mental Capacity Act Code of Practice, and must make decisions in the best interests of the person. (NG108) Lasting power of attorney is a legal document that lets someone appoint one or more people to make decisions on their behalf, should they be unable to. Lasting power of attorney can be made in relation to health and welfare, and property and financial affairs.(NG96).
Deprivation of Liberty Safeguards (DoLS) or equivalent [PRSB]: DoLS are a legal framework applying to individuals who lack the mental capacity to consent to the arrangements for their care. Where such care may amount to a "deprivation of liberty" the arrangements independently assessed to ensure they are in the best interests of the individual concerned.
Mental health act or equivalent [PRSB]: Details about a person diagnosed with a mental disorder, including where they are formally detained under the Mental health act or equivalent and the section number, or if a person is subject to Community Treatment Order or Conditional Discharge (or equivalent).
Advance decision to refuse treatment (ADRT) [PRSB]: Record of an advance decision to refuse one or more specific types of future treatment, made by a person who had capacity at the time of recording the decision. The decision only applies when the person no longer has the capacity to consent to or refuse the specific treatment being considered. An ADRT must be in writing, signed and witnessed. If the ADRT is refusing life-sustaining treatment it must state specifically that the treatment is refused even if the person's life is at risk.
Advance statement [PRSB]: Written requests and preferences made by a person with capacity conveying their wishes, beliefs and values for their future care should they lose capacity.
See the Consent and legal information Conceptual Model for a visualisation of entries and the relationships between them

 

Audit Information: Information about when a record was created, modified, completed and authorised and by whom. All records in the MODS are expected to include audit and provenance information. Every record must be versioned and a log created for every change to a record.

See the Audit Information Conceptual Model for a visualisation of entries and the relationships between them.

 

MODS does not currently include :

Financial information &amp; Financial Assessment
Carer Assessment
Compliance Information

## Glossary
Last updated 31 October, 20241 min read
[A draft glossary and comparison of terms used across adult social care MODS data standards is available here:](https://data.digitisingsocialcare.co.uk/browser/dataset/110069/0)

A downloadable version can be found in the Resources section of the Glossary.

Adult Social Care Record (MODS) Implementation Guidance

adult-social-care-record-mods

https://transform.england.nhs.uk/about-us/

Adult Social Care Record (MODS): Adult Social Care Record (MODS) Implementation Guidance

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