Patient Journal Care Record Elements (Transactional)

Care Record Element Types

Care Record Element Type	Type
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`
Immunisation	`immunisation`
Investigation Report	`investigation-report`
Medication Administration	`medication-administration`
Medication Statement	`medication-statement`
Observation	`observation`
Outbound Referral	`outbound-referral`
Prescription	`prescription`
Procedure	`procedure`
Recall	`recall`

Allergy Intolerance

Property	Type	Description
`id`	uuid	The unique record identifier
`allergyCode`	SNOMED CT Code	A post-coordinated SNOMED CT code for the allergy/intolerance/sensitivity
`substance`	SNOMED CT Code	A SNOMED CT code for the substance that the patient has an allergy/intolerance/sensitivity to
`severity`	enum	Possible values: `mild` `moderate` `severe`
`reactions`	array of SNOMED CT Codes	SNOMED CT codes relating to an allergy/intolerance/sensitivity
`onsetDate`	date (ISO 8601 format)	The onset date of the allergy/intolerance/sensitivity
`certainty`	enum	Possible values: `unlikely` `likely` `certain` `confirmed-by-challenge-testing`
`additionalInformation`	string	Free text to record additional information
`recordDate`	date (ISO 8601 format)	The record creation date
`recordedByPractitioner`	Details of the recording practitioner	Details of the recording practitioner Example payload: JSON `{ "identifierType": "medicus-staff-id, third-party-practitioner-id", "identifier": "AC12345", "name": "Dr Joel Ward" }`
`recordedByOrganisation`	Details of the recording organisation	Details of the recording organisation Example payload: JSON `{ "identifierType": "nhs-england-ods-code", "identifier": "F85003", "name": "Riley House GP Practice" }`
`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

Inbound Document

Property	Type	Description
`id`	uuid
`documentType`	SNOMED CT Code	The SNOMED CT that defines the document type
`title`	string	An optional title for the document.
`file`	The attached file	Example payload: JSON `"file": { "name": "Discharge_Letter.pdf", "size": 3028, "type": "application/pdf", "url": "/transactional-api/v1/file/care-record-document/e148fc20-6b54-11ed-9b61-0a8d9fca48f6/e149121e-6b54-11ed-b412-0a8d9fca48f6" }`
`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

Care Record Note

Property	Type	Description
`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	Details of the recording practitioner Example payload: JSON `{ "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: JSON `{ "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

Communication

Property	Type	Description
`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: CODE `{ "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: CODE `{ "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

Encounter (Consultation)

Property	Type	Description
`id`	uuid
`startDate`	date (ISO 8601 format)	The encounter’s start date
`startTime`	time	The encounter’s start time
`endDateTime`	datetime (ISO 8601 format)	The encounter’s end time
`responsibleOrganisation`	Organisation	The responsible organisation
`responsiblePractitioner`	Practioner	The responsible practitioner
`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
`location`	Location	The encounter’s location
`additionalStaff`	array of Practitioners	Additional staff
`otherParticipants`	array of strings	Other participants in the encounter
`recordedByPractitioner`	Recorded by Practitioner	Details of the recording practitioner Example payload: JSON `{ "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: JSON `{ "identifierType": "nhs-england-ods-code", "identifier": "F85003", "name": "Riley House GP Practice" }`
`consultationTopics`	array	See: Consultation Topic
`recordedDate`	date

Encounter: Consultation Topic

Property	Type	Description
`id`	uuid
`title`	string	The title of the consultation topic
`clinicalCode`	SNOMED CT Code
`headings`	an array of Consulation Topic Headings	The Consultation Topic headings
`linkedProblems`	Problem	(If applicable) An array of references to the linked problem, as set in the Medicus user interface

Encounter: Consultation Topic Heading

Property	Type	Description
`id`	uuid
`title`	string	The title of the consultation topic (the tabs)
`careRecordElements`	array	An array of care record elements (see Care Record Element Types)

eMED3 Fit Note

Property	Type	Description
`id`	uuid	The unique record identifier
`adminCode`	SNOMED CT Code	A SNOMED CT Code that describes the fit note as a record entry.
`file`	The attached file	Details of the file attached to the care record document Example Payload: JSON `{ "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" }`
`assessmentDate`	date (ISO 8601 format)	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

Immunisation

Property	Type	Description
`id`	uuid
`recordDate`	datetime (ISO 8601 format)	The datetime that the vaccination was recorded
`vaccination`	SNOMED CT Code
`product`	Product	Example payload: JSON `{ "dmdCode": "91111000001107" "name": "Paracetamol 500mg tablets", "description": "Paracetamol 500mg tablets (The Boots Company Plc)", "manufacturerName": "The Boots Company Plc", }`
`quantityAdministered`		`unit` (SNOMED CT Code) `value` (decimal) Example payload: JSON `"unit": { "conceptId": "258773002", "description": "Milliliter (qualifier value)", "descriptionId": "258773002" }, "value": 0.5`
`batchNumber`	string
`expiryDate`	date (ISO 8601 format)
`site`	SNOMED CT Code
`route`	SNOMED CT Code
`additionalInformation`	string
`administrationDate`	date (ISO 8601 format)
`administrationTime`	time
`administeredByOrganisation`	Organisation
`administeredByPractitioner`	Practitioner
`recordedByOrganisation`	Organisation
`recordedByPractitioner`	Practitioner
`recordedDate`	date
`linkedProblems`	Problem	(If applicable) An array of references to the linked problem, as set in the Medicus user interface

Investigation Report

Property	Type	Description
`id`	uuid
`requestedByOrganisation`	Organisation
`requestedByDepartment`	string	The requesting department
`requestedByPractitioner`	Practitioner
`requesterComments`	string
`issuedDateTime`	dateTime (ISO 8601 format)
`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
`filedByPractitioner`	Practitioner
`filedByOrganisation`	Organisation
`filedDate`	date
`linkedProblems`	Problem	(If applicable) An array of references to the linked problem, as set in the Medicus user interface

Investigation Report: Investigation Group

Property	Type	Description
`id`	uuid
`type`	SNOMED CT Code
`performerComments`	string
`investigationResults`	Investigation Results (as array)
`specimen`	Specimen

Investigation Report: Investigation Result

Property	Type	Description
`id`	uuid
`type`	SNOMED CT Code
`performedDateTime`	datetime (ISO 8601 format)
`issuedDateTime`	datetime (ISO 8601 format)
`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
`interpretation`	SNOMED CT Code
`performerComments`	string

Investigation Result Reference Range

Property	Type	Description
`lowerReferenceLimit`	decimal
`upperReferenceLimit`	decimal
`description`	null

Investigation Specimen

Property	Type	Description
`id`	uuid
`type`	string
`collectedDateTime`	datetime (ISO 8601 format)
`amountCollected`	Amount Collected Quantity
`fastingStatus`	enum	Possible values: `fasting` Note, a `null` or false value wouldn’t be sent by the provider
`receivedForProcessingDateTime`	datetime (ISO 8601 format)
`performerComments`	string

Amount Collected: Quantity

Parameter Name	Type	Description
`value`	decimal
`unit`	SNOMED CT Code

Medication Administration

Property	Type	Description
`id`	uuid
`product`	Product
`quantityAdministered`	Value: decimal Unit: SNOMED-CT Code	Sample payload JSON `{ "value": 50.1 "unit": { "conceptId": "428673006", "description": "Tablet - unit of product usage (qualifier value)" } }`
`batchNumber`	string
`expiryDate`	date (ISO 8601 format)
`site`	SNOMED CT Code
`route`	SNOMED CT Code
`additionalInformation`	string
`administeredDate`	date (ISO 8601 format)
`administeredTime`	time
`administeredByOrganisation`	Organisation
`administeredByPractitioner`	Practitioner
`recordedByOrganisation`	Organisation
`recordedByPractitioner`	Practitioner
`recordedDate`	date
`linkedProblems`	Problem	(If applicable) An array of references to the linked problem, as set in the Medicus user interface

Medication Statement

Property	Type	Description
`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
`additionalInformation`	string
`prescribedByOrganisation`	Organisation
`prescribedByPractitioner`	Practitioner
`startDate`	date (ISO 8601 format)
`endDate`	date (ISO 8601 format)
`reasonEnded`	string
`recordedByOrganisation`	Recorded by Organisation	Details of the recording organisation Example payload: JSON `{ "identifierType": "nhs-england-ods-code", "identifier": "F85003", "name": "Riley House GP Practice" }`
`recordedByPractitioner`	Recorded by Practitioner	Details of the recording practitioner Example payload: JSON `{ "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

Observation

Property	Type	Description
`id`	uuid
`type`	SNOMED CT Code
`observationDate`	date (ISO 8601 format)
`observationTime`	time
`valueBloodPressure`	Observation Blood Pressure	Example payload: JSON `"bloodPressure": { "systolic":185, "diastolic":85 },`
`bloodPressureUnitOfMeasure`	SNOMED CT Code (always mmHg)	Example payload: JSON `"bloodPressureUnitOfMeasure": { "conceptId": "259018001", "description": "mmHg", "descriptionId": "385726016" }`
`valueQuantity`	Observation Quantity
`valueDate`	date (ISO 8601 format)
`valueDateTime`	dateTime (ISO 8601 format)
`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	(If applicable) An array of references to the linked problem, as set in the Medicus user interface

Observation: Quantity

Property

Type

Description

comparator

enum

Possible values:

[null, '>','≥','<','≤','=']

value

decimal

unit

SNOMED CT Code

Observation: Blood Pressure

Property	Type	Description
`systolic`	decimal
`diastolic`	decimal

Outbound Referral

Property	Type	Description
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.

NHS e-Referral Shortlisted Service

Property	Type	Description
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.

Referral Attachment

Property

Type

Description

id

UUID

file

The attached file

Details of the referral attachment file.

Example Payload:

CODE

{
    "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"
}

Prescription

Property	Type	Description
`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
`authorisedIssues`	int
`reviewDate`	date (ISO 8601 format)	Prescription review date
`dispenserInstructions`	uuid	Any specific instructions to the dispensing organisation about the medication (e.g. Tell patient to stop taking their antibiotics with this medication).
`authorisedDate`	date (ISO 8601 format)
`authorisedByOrganisation`	Organisation
`authorisedByPractitioner`	Practitioner
`status`	enum	Possible values: `['authorised', 'discontinued']`
`discontinuedDate`	date (ISO 8601 format)
`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"]`
`recordedByPractitioner`	Practitioner	name (string) identifier (string) identifierType (enum) values: `medicus-staff-id` `third-party-practitioner-id` Example: CODE `{ "identifierType": "third-party-practitioner-id", "identifier": "AC12345", "name": "Dr Joel Ward" }`
`recordedByOrganisation`	Organisation	name (string) identifier (string) identifierType (enum) values: `nhs-england-ods-code` `medicus-tenant-id` Example: CODE `{ "identifierType": "nhs-england-ods-code", "identifier": "F85003", "name": "Riley House GP Practice" }`
`recordedDate`	date	The date that the prescription was recorded.
`linkedProblems`	Problem	(If applicable) An array of references to the linked problem, as set in the Medicus user interface

Prescription: Quantity

Parameter Name	Type	Description
`unit`	SNOMED CT Code
`value`	decimal

Procedure

Property	Type	Description
`id`	uuid
`procedureCode`	SNOMED CT Code
`bodySite`	SNOMED CT Code
`additionalInformation`	string
`performedDate`	date (ISO 8601 format)
`performedTime`	time
`performedByOrganisation`	Organisation
`performedByPractitioner`	Practitioner
`recordedByPractitioner`	Recorded by Practitioner	Details of the recording practitioner Example payload: JSON `{ "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: JSON `{ "identifierType": "nhs-england-ods-code", "identifier": "F85003", "name": "Riley House GP Practice" }`
`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

Recall

Property	Type	Description
`id`	uuid	Recall Identifier
`clinicalCode`	SNOMED CT Code
`plannedStartDate`	date (ISO 8601 format)
`plannedEndDate`	date (ISO 8601 format)
`details`	string
`status`		Possible values: [`'incomplete'`, `'completed'`, `'cancelled'`]
`recordedByPractitioner`	Recorded by Practitioner	Details of the recording practitioner
`recordedByOrganisation`	Recorded by Organisation	Details of the recording organisation
`linkedProblems`	Problem	(If applicable) An array of references to the linked problem, as set in the Medicus user interface

Linked Problems

For more details on Problems see Linking Care Records to Problems Implementation Guidance.

Property	Type	Description
`problem`	SNOMED CT Code

JSON

"problem": {
    "conceptId": "43116000",
    "description": "Eczema",
    "descriptionId": "71923017"
}

Common Object Schemas

This section documents a series of common schemas that appear across multiple Care Record Elements

Location

Parameter Name	Type	Description
`name`	string	The location's name
`address`	Postal Address (see JSON payload)	If applicable

Sample Payload

JSON

{
    "name": "The Surgery",
    "address": {
                "line1": "The Shire",
                "line2": "24-32 London Rd",
                "line3": "Southfields",
                "locality": "Newbury",
                "administrativeArea": "Berkshire",
                "postalCode": "RG14 1JX",
                "country": "United Kingdom"
  }
}

Organisation

Parameter Name	Type	Description
`name`	string	The organisation's name
`odsCode`	string	The ODS code associated with the location/organisation

Sample Payload

JSON

{
    "name": "Primary Care Group Ltd",
    "odsCode": "ABC123"
}

Postal Address

Parameter Name	Type	Description
`line1`	string	The first line of the addess
`line2`	string	The second line of the addess
`line3`	string	The third line of the addess
`locality`	string	The address' locality
`administrativeArea`	string	The address' administrative area
`postalCode`	string	The address' postal code
`country`	string	The address' country

Sample Payload

JSON

{
    "line1": "The Shire",
    "line2": "24-32 London Rd",
    "line3": "Southfields",
    "locality": "Newbury",
    "administrativeArea": "Berkshire",
    "postalCode": "RG14 1JX",
    "country": "United Kingdom"
}

Practitioner

Parameter Name	Type	Description
`id`	uuid	Unique Medicus user identifier
`name`	string	The name of the practitioner

Sample Payload

JSON

{
    "id": "bc6b8fff-9467-484f-9e79-ac38dedcae67",
    "name": "Dr Smith"
}

Product

Parameter Name	Type	Description
`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

Sample Payload

JSON

"product": {
    "dmdCode": "39230211000001104",
    "name": "COVID-19 Vaccine Janssen (Ad26.COV2-S [recombinant]) 0.5ml dose suspension for injection multidose vials",
    "description": "COVID-19 Vaccine Janssen (Ad26.COV2-S [recombinant]) 0.5ml dose suspension for injection multidose vials",
    "manufacturerName": "Janssen-Cilag Ltd"
}

SNOMED CT Code

Parameter Name	Type	Description
`conceptId`	string	SNOMED CT concept ID
`description`	string	SNOMED CT description
`descriptionId`	string	SNOMED CT description ID

Sample Payload

JSON

{
    "conceptId": "390952000",
    "description": "Allergy to dust",
    "descriptionId": "1484982010"
}

Healthcare Service

Property	Type	Description
`id`	uuid	The ID of the healthcare service
`name`	string	The healthcare service name

Sample Payload

JSON

{
    "id": "0e15b37f-4fed-4648-aec6-06906b9d9214",
    "name": "Children's Wellbeing"
}

Attached File

Property	Type	Description
`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

Sample Payload

JSON

{
    "name": "discharge-summary-template.pdf",
    "size": 25,
    "type": "application/pdf",
    "url": "/transactional-api/v1/file/emed3-fit-note/e0a10fc6-6fda-11ed-84e5-0a58a9feac02/e10fc07e-6fda-11ed-a193-0a58a9feac02"
}