Notice: This guidance is under active development by NHS England and content may be added or updated on a regular basis.
Data mapping - SPCR
Standardised Pharmacy Consultation Record
A pharmacy consultation
Payload: Bundle type document with Composition to GP payload
ADD Mandatory FHIR elements to resources
Bundle (1..*)
| Source Data item | Cardinality | Target FHIR Element | Notes |
|---|---|---|---|
| Bundle type | 1..1 | Bundle.type = "document" | Bundle will be a document with a composition resource |
Composition (1..*)
| Source Data item | Cardinality | Target FHIR Element | Notes |
|---|---|---|---|
| IT System ID - BSA | 1..1 | Composition.Identifier | Version-independent identifier for the Composition |
| Status | 1..1 | Composition.Status | preliminary | final | amended | entered-in-error |
| Type | 1..1 | Composition.Type | Kind of composition - Codesystem |
| Date | 1..1 | Composition.date | Composition editing time |
| Author | 1..1 | Composition.author | Who and/or what authored the composition |
| Title | 1..1 | Composition.title | Human Readable name/title |
| Information and advice given | 1..1 | UKCore-Composition.section (code = Information and advice given) OR in the Encounter resource or Communication resource | The oral, written, or multi-media information or advice given to the person, carer, other authorised representative, care professional or other third party. May include advice about actions related to medicines or other ongoing care activities on an ‘information prescription'. State here if there are concerns about the extent to which the person and/or carer understand the information provided about diagnosis, prognosis and treatment. |
| Information and advice given Coded value | 1..1 | UKCore-Composition.section.code | The coded value for information and advice given. |
| Information and advice given Free text | 1..1 | UKCore-Composition.section.text | Free text field to be used if no code is available |
| Relevant past medical, surgical and mental health history | 1..1 | UKCore-Composition.section (code = History).text | The record of the person’s significant medical, surgical and mental health history. Including relevant previous diagnoses, problems and issues, procedures, investigations, specific anaesthesia issues, etc. (will include dental and obstetric history)A list of the person's relevant past medical, surgical and mental health history recorded in free text or coded form or Information relating to past medical, surgical and mental health history may be provided by the referral document or during the consultation. |
| Free text | 1..1 | UKCore-Composition.section (code = History).text | Free text only allowed for this field, to alleviate any issues with history data conflicting with items already coded onto the GP patient record |
| Clinical narrative | 1..1 | UKCore-Composition.section (code = Clinical Summary).text | A description detailing a patient’s reason for attendance, results from the diagnostic and treatment process and any existing relevant allergies. |
| Plan and requested actions record entry | 1..1 | UKCore-Composition.section (code = Plan and requested actions).text OR Could this be carried in a CarePlan resource | This is a plan and requested actions record entry. |
| Red flag detail | 1..1 | UKCore-Composition.section (code = Red flags).text | Details of any red flag symptoms recorded. |
| Last amended date - BSA | 1..1 | Composition.date ??? or meta.LastUpdated is a better fit | Date and time the of the last amendment to the consultation |
| Date and time the assessment is recorded in system - BSA | 1..1 | ??? | Date and time the consultation is recorded in system. |
Unmapped or Remap check (1..*)
| Source Data item | Cardinality | Target FHIR Element | Notes |
|---|---|---|---|
| Service Mode (prescribing or non-prescribing) - BSA | 1..1 | Extension? | Denotes whether the consultation was carried out using the prescribing, or non-prescribing model |
| BaRS / ITK Referral Reference - BSA | 1..1 | UKCore-Encounter.basedOn -> UKCore-ServiceRequest.identifier | Unique ID of the BaRS or ITK referral |
| Where patient would have gone to instead of pharmacy - BSA | 1..1 | ?????? This is not mapping to anything as it is not clear where the data would be captured from. | For walk-in (self-referred) patients, where would the patient have gone if the parmacy service was not available? |
| Gateway criteria met (Yes/No) - BSA | 1..1 | ??? | Identifier for PGD services denoting whether or not the patient has met the gateway criteria for payment |
| Prescription exemption (yes/no) - BSA | 1..1 | ??? | A record of whether the patient is exempt from NHS prescription charges. |
| Prescription exemption category - BSA | 1..1 | ??? | A record of whether the patient is exempt from NHS prescription charges. |
| Safeguarding concerns & local policy followed | 1..1 | ??? | Capture as Yes/No: Is there a safeguarding concern? Yes/No If yes, have you followed the local safeguarding policy? Yes/No Responses are not to be shared via GP Connect Update Record or to the BSA and will be held in the Local Pharmacy record only |
| Current Contraception type - BSA | 1..1 | Conditional: UKCore-MedicationStatement.medication[x] for a product, or UKCore-Procedure.code for a procedure/device method |
Encounter (1..*)
| Source Data item | Cardinality | Target FHIR Element | Notes |
|---|---|---|---|
| Service - BSA | 1..1 | UKCore-Encounter.serviceType | The pharmacy service that was provided |
| Service sub-type - BSA | 1..1 | UKCore-Encounter.type (service sub-type coding) | Some services have multiple variants that can alter how consultation data entry must be configured. |
| Reason for service - BSA | 1..1 | UKCore-Encounter.reasonCode | The reason why the person has been offered the service. |
| Date and time of contact - BSA | 1..1 | UKCore-Encounter.period.start | Date and time of the contact. |
| Consultation method e.g., face to face - BSA | 1..1 | UKCore-Encounter.type | Consultation method used e.g. face to face, telephone |
ServiceRequest (1..1)
| Source Data item | Cardinality | Target FHIR Element | Notes |
|---|---|---|---|
| Date of referral - BSA | 1..1 | UKCore-ServiceRequest.authoredOn | The date of referral |
| Source of contact - BSA | 0..1 | UKCore-ServiceRequest.category | Was the patient directed to the pharmacy service via a formal referral, a signposting, or did they self-refer (e.g. walk-in)? |
| Referring/ signposting service e.g., GP Practice, NHS111 - BSA | 0..1 | UKCore-ServiceRequest.requester | The service of the referrer. |
| Referring/ signposting service e.g., GP Practice, NHS111 Coded value - BSA | 0..1 | Referenced UKCore-Organization.type | The coded value for service. |
| Referring/ signposting service e.g., GP Practice, NHS111 free text - BSA | 0..1 | Referenced UKCore-Organization.name | Free text field to be used if no code is available. |
| Organisation coded value (ODS code) of referrer - BSA | 0..1 | UKCore-ServiceRequest.requester | The organisation of the referrer/ signpost |
| Onward Referral or signpost | 0..1 | UKCore-ServiceRequest.category | Whether the patient was referred or signposted to another service as an outcome of the consultation |
| Onward Referral/ signpost to: Service e.g., GP Practice | 0..1 | UKCore-ServiceRequest.code | The service to which the patient was signposted or referred |
| Date of onward referral/ signpost | 0..1 | UKCore-ServiceRequest.authoredOn | The date of the onward referral |
| Reason for Onward referral/ signpost | 0..1 | UKCore-ServiceRequest.reasonCode | |
| Urgency of referral - Routine, urgent | 0..1 | UKCore-ServiceRequest.priority | |
| Onward Referral to: Organisation (ODS code) | 0..1 | UKCore-ServiceRequest.performer | |
| Onward Referral to: Organisation Name & Address | 0..1 | UKCore-ServiceRequest.performer | |
| Referral source - BSA | 1..1 | UKCore-ServiceRequest.requester (Device) | What was the source system for the referral? |
Consent (1..*)
| Source Data item | Cardinality | Target FHIR Element | Notes |
|---|---|---|---|
| Consent to share with BSA for payment purposes | 1..1 | UKCore-Consent.provision.type | Flag to provide confirmation that the patient has explicitely provided consent to share their data with the BSA for payment and service reporting purposes |
| Consent for sharing with registered GP (AKA Consent for information sharing) | 1..1 | UKCore-Consent.provision.type | This is a record of consent for information sharing under the common law duty of confidentiality. |
Condition (1..*)
| Source Data item | Cardinality | Target FHIR Element | Notes |
|---|---|---|---|
| Primary presenting complaint or issue - BSA | 1..1 | UKCore-Condition | The health problem or issue experienced by the person resulting in their attendance. This may include disease state, medical condition, response and reactions to therapies. e.g., blackout, dizziness, chest pain, follow up from admission, falls, a specific procedure, investigation or treatment. |
| Primary presenting complaint or issue Coded value - BSA | 1..1 | UKCore-Condition.code | The coded value for presenting complaint or issue |
| Primary presenting complaint or issue Free text - BSA | 1..1 | UKCore-Condition.code.text | Free text |
| Other presenting complaint or issue - BSA | 1..1 | UKCore-Condition | The health problem or issue experienced by the person resulting in their attendance. This may include disease state, medical condition, response and reactions to therapies. e.g., blackout, dizziness, chest pain, follow up from admission, falls, a specific procedure, investigation or treatment. |
| Other presenting complaint or issue Coded value - BSA | 1..1 | UKCore-Condition.code | The coded value for presenting complaint or issue |
| Other presenting complaint or issue Free text - BSA | 1..1 | UKCore-Condition.code.text | Free text entry allowed if appropriate coded value not available |
AllergyIntolerance (1..*)
| Source Data item | Cardinality | Target FHIR Element | Notes |
|---|---|---|---|
| Certainty | 0..1 | UKCore-AllergyIntolerance.type | The type of reaction experienced by the person (allergic, adverse, intolerance) |
| Certainty coded value | 0..1 | UKCore-AllergyIntolerance.verificationStatus.coding | The coded value for certainty. |
| Certainty coded free text | 0..1 | UKCore-AllergyIntolerance.verificationStatus.text | Free text field to be used if no code is available for Certainty. |
| Certainty coded free text | 0..1 | UKCore-AllergyIntolerance.verificationStatus.text | Free text field to be used if no code is available for Certainty. |
| Date first experienced | 0..1 | UKCore-AllergyIntolerance.reaction.onset[x] | When the reaction was first experienced i.e this may not be the first time this has happened. May be a date or partial date (e.g. year) or text (e.g. during childhood) |
| Causative agent | 0..1 | UKCore-AllergyIntolerance.code | 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 |
| Causative agent coded value | 0..1 | UKCore-AllergyIntolerance.code.coding | The coded value for causative agent |
| Causative agent free text | 0..1 | UKCore-AllergyIntolerance.code.text | Free text field to be used when site code is not available (where relevant) |
| Date that the reaction was identified | 0..1 | UKCore-AllergyIntolerance.recordedDate | The date that the reaction was identified. |
| Description of reaction | 0..1 | UKCore-AllergyIntolerance.reaction | A description of the manifestation of the allergic or adverse reaction experienced by the person. For example, skin rash. |
| Description of reaction coded value | 0..1 | UKCore-AllergyIntolerance.reaction.manifestation | The coded value for description of reaction. |
| Description of reaction free text | 0..1 | UKCore-AllergyIntolerance.reaction.manifestation.text | Free text field to be used if no code is available |
| Severity | 0..1 | UKCore-AllergyIntolerance.reaction.severity | A description of the severity of the reaction. |
| Severity coded value | 0..1 | UKCore-AllergyIntolerance.reaction.severity | The coded value for severity |
| Severity free text | 0..1 | UKCore-AllergyIntolerance.reaction.description | Free text field to be used if no code is available |
Medication
| Source Data item | Cardinality | Target FHIR Element | Notes |
|---|---|---|---|
| Form | 0..1 | UKCore-Medication.form | The form of the medication e.g. capsule, drops, tablet, lotion etc. |
| Form Coded value | 1..1 | UKCore-Medication.form.coding | The coded value for form. |
MedicationRequest for Prescribe services
Patient prescription services.
MedicationDispense alone for PGD
Patient Group Directions. Who can supply or administer medicines to patients without a doctor.
MedicationDispense (1..*)
| Source Data item | Cardinality | Target FHIR Element | Notes |
|---|---|---|---|
| Medication name - BSA | 0..1 | UKCore-MedicationDispense.medication[x] | The type of reaction experienced by the person (allergic, adverse, intolerance) |
| Medication coded value - BSA | 0..1 | UKCore-MedicationDispense.medicationCodeableConcept.coding | The coded value for medication name |
| Medication free text | 0..1 | UKCore-MedicationDispense.medicationCodeableConcept.text | Free text value where coded item not available for medication name |
| Quantity - BSA | 0..1 | UKCore-MedicationDispense.quantity | The quantity of the medication (e.g. tablets, inhalers, etc.) provided to the person. This may be dispensed by the pharmacy or on the ward. Record in a structured format i.e. value and a unit |
| Value - BSA | 0..1 | UKCore-MedicationDispense.quantity.value | The value of the quantity supplied |
| Units of measure - BSA | 0..1 | UKCore-MedicationDispense.quantity.unit | Units of measure of quantity supplied |
| Supply period (in days) - BSA | 0..1 | UKCore-MedicationDispense.daysSupply | The number of days supply that the quantity provided will cover |
| Date supplied - BSA | 0..1 | UKCore-MedicationDispense.whenHandedOver | The date/time the medication was supplied (or in the case of prescribing, the date prescribed). |
| Supply type pre-defined text e.g., OTC, PGD - BSA | 0..1 | UKCore-MedicationDispense.type | A description of the type of supply (e.g. emergency supply, over the counter medication, patient group direction etc) |
| Dose directions description e.g., “1 tablet at night. Max dose X | 0..1 | UKCore-MedicationDispense.dosageInstruction | Describes the entire medication dosage and administration directions including dose quantity and medication frequency and optionally duration e.g. “1 tablet at night" or “2mg at 10pm”. |
| Structured dose amount | 0..1 | UKCore-MedicationDispense.dosageInstruction.doseAndRate.dose[x] | A structural representation of dose amount, e.g. 20mg or 2 tablets. This element will generally only be used when persisting data within systems with 'parsable dose directions' being used to exchange the same information between systems. As per FHIR Dose Syntax Implementation Guidance (NHS Digital): https://simplifier.net/guide/DoseSyntaxImplementationGuidanceforFHIRR4/Home |
| Structured dose timing | 0..1 | UKCore-MedicationDispense.dosageInstruction.timing | A slot containing a structural, computable representation of dose timing and maximum dose. This element will generally only be used when persisting data within systems with 'parsable dose directions' being used to exchange the same information between systems. As per FHIR Dose Syntax Implementation Guidance (NHS Digital): https://simplifier.net/guide/DoseSyntaxImplementationGuidanceforFHIRR4/Home |
| Dose duration direction | 0..1 | UKCore-MedicationDispense.dosageInstruction.timing.repeat.bounds[x] | Recommendation of the time period for which the medication should be continued, including direction not to discontinue. As per FHIR Dose Syntax Implementation Guidance (NHS Digital): https://simplifier.net/guide/DoseSyntaxImplementationGuidanceforFHIRR4/Home |
| Dose directions description | 0..1 | UKCore-MedicationDispense.dosageInstruction.text | Describes the entire medication dosage and administration directions including dose quantity and medication frequency and optionally duration e.g. “1 tablet at night" or “2mg at 10pm”. |
| Additional instructions e.g., dissolve under tongue, avoid alcohol | 0..1 | UKCore-MedicationDispense.dosageInstruction.additionalInstruction | Allows for: requirements for adherence support, e.g. compliance aids, prompts and packaging requirements, additional information about specific medicines e.g. where specific brand required, person requirements, e.g. unable to swallow tablets. |
| Route - BSA | 0..1 | UKCore-MedicationDispense.dosageInstruction.route | The route by which the medication is administered e.g. oral, IM, IV |
| Route Coded value - BSA | 0..1 | UKCore-MedicationDispense.dosageInstruction.route.coding | The coded value for route |
| Site | 0..1 | UKCore-MedicationDispense.dosageInstruction.site | The anatomical site at which the medication is to be administered. |
| Site coded value | 0..1 | UKCore-MedicationDispense.dosageInstruction.site.coding | The coded value for site |
| No supply reason - BSA | 0..1 | UKCore-MedicationDispense.statusReason[x] (normally statusReasonCodeableConcept) | The reason that medication has not been supplied. |
Observation (1..*)
| Source Data item | Cardinality | Target FHIR Element | Notes |
|---|---|---|---|
| Observation | 1..1 | UKCore-Observation | The record of essential physiological measurements, e.g., heart rate, blood pressure, temperature, pulse, height, weight, respiratory rate, oxygen saturation. |
| Observation Coded value | 1..1 | UKCore-Observation.code | The coded value for the observation |
| Observation Value | 1..1 | UKCore-Observation.value[x] | The value of the observation. |
| Units of measure | 1..1 | UKCore-Observation.valueQuantity.unit / .code / .system (UCUM) | The units of measure for observation |
| Site | 1..1 | UKCore-Observation.bodySite | The anatomical site at which the observation is taken (where relevant) |
| Site Coded value | 1..1 | UKCore-Observation.bodySite.coding | The coded value for site (where relevant) |
| Site Free Text | 1..1 | UKCore-Observation.bodySite.text | Free text field to be used when site code is not available (where relevant) |
| Pregnancy Status | 1..1 | Conditional: UKCore-MedicationStatement.medication[x] for a product, or UKCore-Procedure.code for a procedure/device method | Is the patient pregnant or do they think they are pregnant? |