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

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.

%%{ init: { 'theme': 'base' } }%% graph TD %% Top Level Observation Types (Inheritance) subgraph ObservationTypes [Types of Observation] direction LR Problem ~~~ Allergies ~~~ Alert ~~~ InvRes[Investigation Result] ~~~ Outcome Incident ~~~ SafCon[Safeguarding Concern] ~~~ Need ~~~ Strength ~~~ Risk Circumstance ~~~ DailyLiving[Daily Living] ~~~ Preferences ~~~ Wishes ~~~ Environment end %% Core Entity Observation((Observation)) %% Central Relationships with Cardinality Observation -- "is a" --> ObservationTypes SubjectOfCare -- "1 refers to 0..*" --> Observation CareActor -- "1 records 0..*" --> Observation Observation -- "0..* involves 0..*" --> CareActor Observation -- "1..* performed in 1" --> Location %% Downstream Influences Observation -- "influences 0..*" --> Review Observation -- "influences 0..*" --> CarePlan[Care Plan] Observation -- "influences 0..*" --> Assessment Observation -- "influences 0..*" --> Instruction

Observations are recorded by a Care Actor and refer to the Subject of care.

An Observation is performed in a Location and multiple Care Actors could be involved. Observations influence Assessments, Care plans and Instructions, as well as being a trigger for Reviews.

Observations recorded as part of social care provision including:

Needs Risks Safeguarding concerns Strengths Wishes Preferences Daily Living Alert Incident Circumstance (including Environment) Outcome Some Observations would typically be recorded as part of healthcare provision such as:

Allergies Investigation Results Problem list and should be shared with adult social care providers and included in an Adult Social Care record.

Page last updated: 05 March 2026