Patient Journal Care Record Elements (PFS)

Allergy Intolerance

allergy-intolerance

Inbound Document

inbound-document

Care Record Note

care-record-note

Communication

communication

Encounter (Consultation)

encounter

eMED3 Fit Note

emed3-fit-note

Investigation Report

investigation-report

Medication Administration

medication-administration

Medication Statement

medication-statement

Observation

observation

Outbound Referral

outbound-referral

Prescription

prescription

Procedure

procedure

Vaccine Administration

vaccine-administration

Problem

problem

id

uuid

The unique record identifier

✅

✅

✅

allergyCode

SNOMED CT Code

A post-coordinated SNOMED CT code for the allergy

✅

✅

✅

substance

SNOMED CT Code

A SNOMED CT code for the substance

✅

✅

✅

severity

enum

Possible values:

• mild

• moderate

• severe

✅

✅

✅

reactions

array of SNOMED CT Codes

SNOMED CT codes relating to the reaction

✅

✅

✅

onsetDate

date

The onset dat

✅

✅

✅

certainty

enum

Possible values:

• unlikely

• likely

• certain

• confirmed-by-challenge-testing

✅

✅

✅

additionalInformation

text

Free text to record additional information

❌

❌

✅

recordDate

date

The record creation date

✅

✅

✅

recordedByPractitioner

Recorded by Practitioner

mandatory

Details of the recording practitioner

✅

✅

✅

recordedByOrganisation

Recorded by Organisation

mandatory

Details of the recording organisation

✅

✅

✅

status

Enum

The status of the allergy.

Possible values:

• active

• ended

✅

✅

✅

linkedProblems

Problem

(If applicable) A reference to the linked problem, set in the Medicus U

✅

✅

✅

id

uuid

❌

✅

✅

documentType

SNOMED CT Code

The SNOMED CT that defines the document type

❌

✅

✅

title

string

An optional title for the document.

❌

❌

✅

file

Attached File

Details of the attached file

❌

❌

✅

clinicalSpecialty

SNOMED CT Code

❌

✅

✅

authoredByOrganisation

Organisation

The organisation that authored the document”

❌

✅

✅

authoredByPractitioner

Practitioner

The practitioner that authored the document

❌

✅

✅

linkedProblems

Problem

(If applicable) An array of references to the linked problem, as set in the Medicus user interface

❌

✅

✅

id

uuid

The unique record identifier

❌

✅

✅

code

SNOMED CT Code

The SNOMED CT code associated with the note

❌

✅

✅

note

string

The note body/content of the note

❌

❌

✅

recordedByPractitioner

Recorded by Practitioner

mandatory

Details of the recording practitioner

❌

✅

✅

recordedByOrganisation

Recorded by Organisation

mandatory

Details of the recording organisation

❌

✅

✅

recordedDate

date

The date on which the fact was recorded

❌

✅

✅

linkedProblems

Problem

(If applicable) An array of references to the linked problem, as set in the Medicus user interface

❌

✅

✅

id

uuid

The unique record identifier

❌

✅

✅

code

SNOMED CT Code

The SNOMED CT code associated with the outbound communication

❌

✅

✅

summary

string

A free text summary for the outbound communication

❌

❌

✅

deliveryMethod

enum

The method of communication used e.g. SMS.

Options:

• SMS

❌

✅

✅

recordedByPractitioner

Recorded by Practitioner

Details of the recording practitioner

Example payload:

{
    "identifierType": "medicus-staff-id, third-party-practitioner-id",
    "identifier": "AC12345",
    "name": "Dr Joel Ward"
}

❌

✅

✅

recordedByOrganisation

Recorded by Organisation

Details of the recording organisation

Example payload:

{
    "identifierType": "nhs-england-ods-code",
    "identifier": "F85003",
    "name": "Riley House GP Practice"
}

❌

✅

✅

recordedDate

date (ISO 8601 format)

The date on which the fact was recorded

❌

✅

✅

linkedProblems

Problem

(If applicable) An array of references to the linked problem, as set in the Medicus user interface

id

uuid

❌

✅

✅

seenInEstablishment

SNOMED CT Code

❌

✅

✅

startDate

date

❌

✅

✅

startTime

time

Optional

❌

✅

✅

endDateTime

datetime

Optional

❌

✅

✅

responsibleOrganisation

Organisation

❌

✅

✅

responsiblePractitioner

Practioner

❌

✅

✅

description

string

An optional property to support import data from other system. This property is never set from the Medicus user interface.

❌

❌

✅

deliveryMode

SNOMED CT Code

Possible values:

• Face-to-face

  • concept ID 325861000000105

• Phone

  • concept ID 325891000000104

• Video

  • concept ID 325921000000107

❌

✅

✅

location

Location

❌

✅

✅

additionalStaff

array of Practitioners

❌

✅

✅

otherParticipants

array of strings

❌

❌

✅

recordedByPractitioner

Recorded by Practitioner

mandatory

Details of the recording practitioner

❌

✅

✅

recordedByOrganisation

Recorded by Organisation

mandatory

Details of the recording organisation

❌

✅

✅

consultationTopics

array

❌

✅

✅

recordedDate

date

❌

✅

✅

id

uuid

❌

✅

✅

title

string

The title of the consultation topic

❌

✅

✅

clinicalCode

SNOMED CT Code

❌

✅

✅

headings

an array of Consulation Topic Headings

❌

✅

✅

linkedProblems

an array of linked Problems

(If applicable) An array of references to the linked problem, as set in the Medicus user interface

❌

✅

✅

id

uuid

❌

✅

✅

title

string

The title of the consultation topic

❌

✅

✅

careRecordElements

array

An array of care record elements

❌

✅

✅

id

uuid

The unique record identifier

❌

✅

✅

adminCode

SNOMED CT Code

A SNOMED CT Code that describes the fit note as a record entry.

❌

✅

✅

file

Attached File

The file attached to the record

❌

❌

✅

assessmentDate

date

The date that the assessment took place.

❌

✅

✅

assessedByPractitioner

Practitioner

The assessing practitioner.

❌

✅

✅

assessedByOrganisation

Organisation

The assessing organisation.

❌

✅

✅

recordedDate

Date

The fit note's recorded date.

❌

✅

✅

recordedByPractitioner

Practitioner

The recording practitioner.

❌

✅

✅

recordedByOrganisation

Organisation

The recording organisation.

❌

✅

✅

linkedProblems

Problem

(If applicable) An array of references to the linked problem, as set in the Medicus user interface

❌

✅

✅

id

uuid

❌

✅

✅

requestedByOrganisation

Organisation

❌

✅

✅

requestedByDepartment

string

The requesting department

❌

✅

✅

requestedByPractitioner

Practitioner

❌

✅

✅

requesterComments

string

❌

❌

✅

issuedDateTime

dateTime

❌

✅

✅

performedByOrganisation

Organisation

❌

✅

✅

performedByDepartment

string

❌

✅

✅

performedByPractitioner

Practitioner

❌

✅

✅

investigationGroups

An array of Investigation Groups

❌

✅

✅

investigationResults

An array of
Investigation Results

❌

✅

✅

specimens

An array of Specimens

❌

✅

✅

filingComments

An array of filing comment as strings

❌

❌

✅

linkedProblems

Problem

(If applicable) An array of references to the linked problem, as set in the Medicus user interface

❌

✅

✅

filedByPractitioner

Practitioner

❌

✅

✅

filedByOrganisation

Organisation

❌

✅

✅

filedDate

date

❌

✅

✅

id

uuid

❌

✅

✅

type

SNOMED CT Code

❌

✅

✅

performerComments

string

❌

❌

✅

investigationResults

Investigation Results (as array)

❌

✅

✅

specimen

Specimen

❌

✅

✅

id

uuid

❌

✅

✅

type

SNOMED CT Code

❌

✅

✅

performedDateTime

datetime

❌

✅

✅

issuedDateTime

datetime

❌

✅

✅

resultStatus

enum

Possible values:

[not-available, preliminary, final, amended]

❌

✅

✅

resultComparator

enum

Possible values:

[null, >,≥,<,≤,=]

❌

✅

✅

resultValue

decimal

❌

✅

✅

resultUnit

SNOMED CT Code

❌

✅

✅

resultText

string

❌

❌

✅

resultCode

SNOMED CT Code

❌

✅

✅

approximateResult

bool

❌

✅

✅

referenceRange

array of Reference Ranges (see below)

❌

✅

✅

interpretation

SNOMED CT Code

❌

✅

✅

performerComments

string

❌

❌

✅

lowerReferenceLimit

decimal

❌

✅

✅

upperReferenceLimit

decimal

❌

✅

✅

description

null

❌

✅

✅

id

uuid

❌

✅

✅

type

string

❌

✅

✅

collectedDateTime

datetime

❌

✅

✅

amountCollected

Amount Collected Quantity

❌

✅

✅

fastingStatus

enum

Possible values:

• fasting

Note, a null or false value wouldn’t be sent by the provider

❌

✅

✅

receivedForProcessingDateTime

datetime

❌

✅

✅

performerComments

string

❌

❌

✅

value

decimal

unit

SNOMED CT Code

id

uuid

❌

✅

✅

product

Product

❌

✅

✅

quantityAdministered

Medication Administration Quantity

❌

✅

✅

batchNumber

string

❌

✅

✅

expiryDate

date

❌

✅

✅

site

SNOMED CT Code

❌

✅

✅

route

SNOMED CT Code

❌

✅

✅

additionalInformation

string

❌

❌

✅

administeredDate

date

❌

✅

✅

administeredTime

time

❌

✅

✅

administeredByOrganisation

Organisation

❌

✅

✅

administeredByPractitioner

Practitioner

❌

✅

✅

linkedProblems

Problem

(If applicable) An array of references to the linked problem, as set in the Medicus user interface

❌

✅

✅

recordedByOrganisation

Organisation

❌

✅

✅

recordedByPractitioner

Practitioner

❌

✅

✅

recordedDate

date

❌

✅

✅

value

decimal

unit

SNOMED CT Code

id

uuid

✅

✅

✅

type

enum

Possible values: [prescribed-elsewhere, over-the-counter]

✅

✅

✅

status

enum

Possible values: [active, ended]

✅

✅

✅

product

Product

✅

✅

✅

prescriptionType

enum

Possible values: [acute, repeat]

✅

✅

✅

dosageInstructions

string

✅

✅

✅

prescribedByOrganisation

Organisation

✅

✅

✅

prescribedByPractitioner

Practitioner

✅

✅

✅

endDate

date

✅

✅

✅

reasonEnded

string

❌

❌

✅

recordedByOrganisation

Recorded by Organisation

Details of the recording organisation

Example payload:

{
    "identifierType": "nhs-england-ods-code",
    "identifier": "F85003",
    "name": "Riley House GP Practice"
}

✅

✅

✅

recordedByPractitioner

Recorded by Practitioner

Details of the recording practitioner

Example payload:

{
    "identifierType": "medicus-staff-id, third-party-practitioner-id",
    "identifier": "AC12345",
    "name": "Dr Joel Ward"
}

✅

✅

✅

recordedDate

date

✅

✅

✅

linkedProblems

Problem

(If applicable) An array of references to the linked problem, as set in the Medicus user interface

✅

✅

✅

id

uuid

❌

✅

✅

type

SNOMED CT Code

❌

✅

✅

observationDate

date

❌

✅

✅

observationTime

time

❌

✅

✅

valueBloodPressure

Observation Blood Pressure

Example payload:

"bloodPressure": {
    "systolic":185,
    "diastolic":85
},

❌

✅

✅

bloodPressureUnitOfMeasure

SNOMED CT Code (always mmHg)

Example payload:

"bloodPressureUnitOfMeasure": {
    "conceptId": "259018001",
    "description": "mmHg",
    "descriptionId": "385726016"
}

❌

✅

✅

valueQuantity

Observation Quantity

❌

✅

✅

valueDate

date

❌

✅

✅

valueDateTime

dateTime

❌

✅

✅

valueCoded

SNOMED CT Code

❌

✅

✅

valueString

string

❌

✅

✅

bodySite

SNOMED CT Code

❌

✅

✅

interpretation

SNOMED CT Code

❌

✅

✅

additionalInformation

string

❌

❌

✅

observedByOrganisation

Organisation

❌

✅

✅

observedByPractitioner

Practitioner

❌

✅

✅

recordedByOrganisation

Organisation

The organisation that recorded the fact

❌

✅

✅

recordedByPractitioner

Practitioner

The practitioner who recorded the fact

❌

✅

✅

recordedDate

date

The date on which the fact was recorded

❌

✅

✅

linkedProblems

Problem (see below)

(If applicable) An array of references to the linked problem, as set in the Medicus user interface

❌

✅

✅

comparator

enum

Possible values:

[null, >,≥,<,≤,=]

value

decimal

unit

SNOMED CT Code

systolic

string

diastolic

string

id

uuid

Problem ID

problem

SNOMED CT Code

id

UUID

❌

✅

✅

type

enum

The type of referral.

Options:

• NHS e-Referral

• Manual

❌

✅

✅

priority

enum

The priority of the referral.

Options:

• Routine

• Urgent

• Two Week Wait

❌

✅

✅

uniqueBookingReferenceNumber

string

NHS e-Referrals only: The e-RS unique booking reference number.

❌

✅

✅

referralDate

localDate

The care record date for the referral as specified by the referrer.

Note, this property can have different meaning depending on the local organisation.

In Medicus, it is intended to capture the date the decision to refer was made.

❌

✅

✅

referralCode

snomedCTCode

A SNOMED CT code to describe the referral.

❌

✅

✅

clinicalSpecialty

snomedCTCode

A SNOMED CT code containing the clinical specialty of the referral.

❌

✅

✅

referredToProvider

organisationInformation

Manual referral only: A property to store the provider the referral was made to.

❌

✅

✅

referredToService

healthcareServiceInformation

Manual referral only: A property to store the service the referral was made to.

❌

✅

✅

referredToPractitioner

practitionerInformation

Manual referral only: A property to store the practitioner the referral was made to.

❌

✅

✅

shortlistedServices

Array of Shortlisted Services

NHS e-Referrals only: The services that the patient/clinician shortlisted as part of the referral request.

❌

✅

✅

referredByOrganisation

organisationInformation

The organisation that referred the patient.

❌

✅

✅

referredByPractitioner

practitionerInformation

The practitioner who referred the patient.

❌

✅

✅

additionalInformation

string

A free text field to capture any additional information about the referral.

❌

❌

✅

referralAttachments

An array of referral attachments

❌

❌

✅

recordedDate

localDate

The date that the referral was recorded in the clinical system.

❌

✅

✅

recordedByOrganisation

organisationInformation

The organisation that recorded the referral.

❌

✅

✅

recordedByPractitioner

practitionerInformation

The practitioner who recorded the referral.

❌

✅

✅

cancellationReason

string

If the referral was cancelled, a string containing information about the cancellation.

❌

❌

✅

id

UUID

provider

organisationInformation

The provider the of the shortlisted service.

service

healthcareServiceInformation

The name and identifier of the service.

practitioner

practitionerInformation

The named practitioner of the service if there was a specific named practitioner.

id

UUID

file

The attached file

Details of the referral attachment file.

Example Payload:

{
    "name": "discharge-summary-template.pdf",
    "size": 25,
    "type": "application/pdf",
    "url": "/transactional-api/v1/file/eMED3FitNote/ed8544c8-f177-11ec-a49a-06c9b1dae9f2/ed8544c8-f177-11ec-a49a-06c9b1dae9f2"
}

id

uuid

The unique prescription identifier

✅

✅

✅

type

enum

The type of prescription

Possible values: [acute, repeat, repeat-dispensing, instalment]

✅

✅

✅

product

Product

The prescription’s pharmaceutical product

✅

✅

✅

dosageInstructions

string

✅

✅

✅

additionalInstructions

string

✅

✅

✅

authorisedIssues

int

✅

✅

✅

reviewDate

date

Prescription review date

✅

✅

✅

authorisedDate

date

✅

✅

✅

authorisedByOrganisation

Organisation

✅

✅

✅

authorisedByPractitioner

Practitioner

✅

✅

✅

discontinuedDate

date

✅

✅

✅

status

enum

Possible values: [authorised, discontinued]

✅

✅

✅

discontinuedReason

enum

Possible values:

[change-of-dosage,clinical-contra-indication,other-clinical-reason,patient-death,patient-deducted,patients-request,pharmacists-request,prescribing-error,prescription-not-collected,product-no-longer-available,product-no-longer-effective]

✅

✅

✅

linkedProblems

Problem

(If applicable) An array of references to the linked problem, as set in the Medicus user interface

✅

✅

✅

unit

SNOMED CT Code

value

decimal

id

uuid

❌

✅

✅

procedureCode

SNOMED CT Code

❌

✅

✅

bodySite

SNOMED CT Code

❌

✅

✅

additionalInformation

string

❌

❌

✅

performedDate

date

❌

✅

✅

performedTime

time

❌

✅

✅

performedByOrganisation

Organisation

❌

✅

✅

performedByPractitioner

Practitioner

❌

✅

✅

recordedByPractitioner

Recorded by Practitioner (See below)

mandatory

Details of the recording practitioner

❌

✅

✅

recordedByOrganisation

Recorded by Organisation

(See below)

mandatory

Details of the recording organisation

❌

✅

✅

recordedDate

date

The date on which the fact was recorded

❌

✅

✅

linkedProblems

Problem

(If applicable) An array of references to the linked problem, as set in the Medicus user interface

❌

✅

✅

id

uuid

❌

✅

✅

vaccination

SNOMED CT Code

❌

✅

✅

product

Product

Example payload:

{
    "dmdCode": "91111000001107"
    "name": "Paracetamol 500mg tablets",
    "description": "Paracetamol 500mg tablets (The Boots Company Plc)",
    "manufacturerName": "The Boots Company Plc",
}

❌

✅

✅

quantityAdministered

Immunisation Administration Quantity (see below)

❌

✅

✅

batchNumber

string

❌

✅

✅

expiryDate

date

❌

✅

✅

site

SNOMED CT Code

❌

✅

✅

route

SNOMED CT Code

❌

✅

✅

additionalInformation

string

❌

❌

✅

administrationDate

date

❌

✅

✅

administrationTime

time

❌

✅

✅

administeredByOrganisation

Organisation

❌

✅

✅

administeredByPractitioner

Practitioner

❌

✅

✅

linkedProblems

Problem

(If applicable) An array of references to the linked problem, as set in the Medicus user interface

❌

✅

✅

recordedByOrganisation

Organisation

❌

✅

✅

recordedByPractitioner

Practitioner

❌

✅

✅

recordedDate

date

❌

✅

✅

value

decimal

unit

SNOMED CT Code

id

uuid

Problem ID

❌

✅

✅

problem

SNOMED CT Code

❌

✅

✅

odsCode

string

The ODS code associated with the location

name

string

The location's name

address

If applicable

line1

string

line2

string

line3

string

locality

string

administrativeArea

string

postalCode

string

country

string

name

string

The organisation's name

odsCode

string

The ODS code associated with the location/organisation

id

uuid

Unique Medicus user identifier

name

string

The name of the practitioner

dmdCode

string

Dictionary of medicines and devices code

name

string

Product name

description

string

A description of the product

manufacturerName

string

The name of the product’s manufacturer

conceptId

string

SNOMED CT concept ID

description

string

SNOMED CT description

descriptionId

string

SNOMED CT description ID

id

uuid

name

string

name

string

The filename

size

int

The filesize in megabytes

type

string

The file’s MIME type

url

string

The URL required to retrieve the file