Data Dictionary: Overview
- Adam Milward
- Charlotte Reynolds
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 & 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 https://specifications.openehr.org/releases/RM/latest/ehr.html#_model_overview:
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 & 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 & Financial Assessment
Carer Assessment
Compliance Information