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FHIR IG Statistics: Questionnaire/Questionnaire-About me

Packagenotts.scr.poc
Resource TypeQuestionnaire
IdQuestionnaire-About me
FHIR VersionR3
Sourcehttps://simplifier.net/resolve?scope=notts.scr.poc@0.1.0&canonical=http://fhir.nottinghamshire.gov.uk/STU3/Questionnaire/About-Me
URLhttp://fhir.nottinghamshire.gov.uk/STU3/Questionnaire/About-Me
Version1.2.0
Statusdraft
Date2021-04-30T12:00:00.000+01:00
NameAbout me
TitleAbout me
DescriptionThis is a record of the things that a person feels it is important to communicate about their needs, strengths, values, concerns and preferences to others providing support and care.
PurposeThe expectation is that this information would be written or recorded by an individual (or someone supporting them) in an electronic record for that individual. How the information is recorded and added to the electronic record is for local determination. The information in the About Me section should be prominent and one of the first sections viewed in a health and care record as it includes important information about the person relevant to all care and support providers. Ideally this information is also available in a multimedia format e.g., video, particularly when a person has difficulties expressing themselves. The information in the About Me section should sit alongside other information entered by health and social care professionals such as medications and allergies to enable the information to be cross-checked. Local implementations will need to define how and where the information is displayed. It should be possible for the individual to update the information as it changes or when they need to record new information. A record of the changes that were made and when they were made should be captured. It is recommended that About Me information is reviewed and updated at key transition points for example for children and young people with Education, Health and Care (EHC) plans when transitioning from primary to secondary school, moving onto college and whenever their home circumstances change (for example moving into supported living or residential care). The transition process from children’s social care to adult’s social care is also a recommended time for reviewing and updating About Me information. For adults, it should be reviewed and updated at planned reviews or when requested by the individual It is the intention that everyone should be able to record About Me information however local implementers may want to identify population groups for which the ability to record and share this type of information would deliver most benefit and start with those groups for example children and young people accessing children and adolescent mental health services (CAMHS), children and young people with an EHC plan, older people in care homes, people living with long term conditions and individuals receiving support from children’s and adult’s social care. The information in the About Me section is intended to be used to support direct care and not to assess an individual’s right to receive care or support.

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Narrative

Note: links and images are rebased to the (stated) source

Professional Record Standards Body (PRSB) - About me standard v1.2

About Me

The expectation is that this information would be written or recorded by an individual (or someone supporting them) in an electronic record for that individual. How the information is recorded and added to the electronic record is for local determination.

The information in the About Me section should be prominent and one of the first sections viewed in a health and care record as it includes important information about the person relevant to all care and support providers. Ideally this information is also available in a multimedia format e.g., video, particularly when a person has difficulties expressing themselves.

The information in the About Me section should sit alongside other information entered by health and social care professionals such as medications and allergies to enable the information to be cross-checked.

Local implementations will need to define how and where the information is displayed.

It should be possible for the individual to update the information as it changes or when they need to record new information. A record of the changes that were made and when they were made should be captured.

It is recommended that About Me information is reviewed and updated at key transition points for example for children and young people with Education, Health and Care (EHC) plans when transitioning from primary to secondary school, moving onto college and whenever their home circumstances change (for example moving into supported living or residential care). The transition process from children’s social care to adult’s social care is also a recommended time for reviewing and updating About Me information. For adults, it should be reviewed and updated at planned reviews or when requested by the individual

It is the intention that everyone should be able to record About Me information however local implementers may want to identify population groups for which the ability to record and share this type of information would deliver most benefit and start with those groups for example children and young people accessing children and adolescent mental health services (CAMHS), children and young people with an EHC plan, older people in care homes, people living with long term conditions and individuals receiving support from children’s and adult’s social care.

The information in the About Me section is intended to be used to support direct care and not to assess an individual’s right to receive care or support.

What it is

  • a section within the Core Information Standard and transfer of care standards which is designed for sharing information that the person (or somebody acting on their behalf) considers important to share about themselves with others caring for or supporting them for the purposes of direct care, to enable the best, personalised care and support to be provided
  • aimed at capturing an individual’s needs, preferences and wishes for how they receive care and support in a person-centred approach. It could also include information on the individual’s strengths to provide a basis for building upon personal and community assets to enable self-care where possible
  • aimed at capturing holistic information about the individual, not just what people caring for and supporting the individual need to know when someone is unwell (or in an emergency) but what they are able to do and enjoy on a typical day
  • divided into sub-categories of information to help individuals to determine what information to share and to help those providing care and support to the individual to easily locate the information they need
  • designed to be generic and apply to everyone, from those who have complex care and support needs to those who rarely require care and/or support. This could include, for example, older people, people with mental health conditions, people with learning disabilities, people with physical impairments and people with long-term conditions etc.

What it is not:

  • intended to be used for determining an individual’s right to access social care or health services
  • a person-held record, therefore, does not include any information recorded by professionals in an electronic patient record such as medications, problems, examination findings and investigation results. In a shared care record the About Me (information from the person themselves) would sit alongside clinical and social care information recorded by professionals about the person
  • a care or support plan. Individuals may have an end-of-life care plan, plans for management of specific conditions or situations (e.g., an asthma management plan or a behaviour support plan) and these would sit alongside the About Me information in a shared care record
  • a go-to section for legal information such as Deprivation of Liberty Safeguards, Lasting Power of Attorney, Nearest relative or Next of Kin
  • a prescriptive definition of what must be included. The About Me section enables an individual to reflect their unique position. They can include whatever information they choose in an About Me section and they can choose not to share any information at all
  • a definition of who should be able to see the information in the About Me section for an individual (local implementers will need to determine this based on the legal framework and NHS England’s Information Governance Framework and Role-Based Access Control framework)
  • a definition of how the information in the About Me section should be presented to professionals. What is presented and how much information (history) and how it is viewed and accessed should be defined locally
  • a definition of a form or system for capturing information in the About Me section from an individual
  • a definition of how and where individuals can record information in the About Me section, how it is captured and displayed in clinical systems and shared records, how it is kept up-to-date and how multiple versions of information in the About Me section are managed (e.g., About Me records originating in different settings)

Source

{
  "resourceType": "Questionnaire",
  "text": {
    "status": "additional",
    "div": "<!-- snip (see above) -->"
  },
  "url": "http://fhir.nottinghamshire.gov.uk/STU3/Questionnaire/About-Me",
  "version": "1.2.0",
  "name": "About me",
  "title": "About me",
  "status": "draft",
  "date": "2021-04-30T12:00:00.000+01:00",
  "publisher": "NottsICS",
  "description": "This is a record of the things that a person feels it is important to communicate about their needs, strengths, values, concerns and preferences to others providing support and care.",
  "purpose": "The expectation is that this information would be written or recorded by an individual (or someone supporting them) in an electronic record for that individual. How the information is recorded and added to the electronic record is for local determination.\nThe information in the About Me section should be prominent and one of the first sections viewed in a health and care record as it includes important information about the person relevant to all care and support providers. Ideally this information is also available in a multimedia format e.g., video, particularly when a person has difficulties expressing themselves.\nThe information in the About Me section should sit alongside other information entered by health and social care professionals such as medications and allergies to enable the information to be cross-checked.\nLocal implementations will need to define how and where the information is displayed.\nIt should be possible for the individual to update the information as it changes or when they need to record new information. A record of the changes that were made and when they were made should be captured.\nIt is recommended that About Me information is reviewed and updated at key transition points for example for children and young people with Education, Health and Care (EHC) plans when transitioning from primary to secondary school, moving onto college and whenever their home circumstances change (for example moving into supported living or residential care). The transition process from children’s social care to adult’s social care is also a recommended time for reviewing and updating About Me information. For adults, it should be reviewed and updated at planned reviews or when requested by the individual\nIt is the intention that everyone should be able to record About Me information however local implementers may want to identify population groups for which the ability to record and share this type of information would deliver most benefit and start with those groups for example children and young people accessing children and adolescent mental health services (CAMHS), children and young people with an EHC plan, older people in care homes, people living with long term conditions and individuals receiving support from children’s and adult’s social care.\nThe information in the About Me section is intended to be used to support direct care and not to assess an individual’s right to receive care or support.",
  "subjectType": [
    "Patient"
  ],
  "item": [
    {
      "linkId": "1",
      "text": "What is most important to me",
      "type": "group",
      "required": false,
      "item": [
        {
          "extension": [
            {
              "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
              "valueCodeableConcept": {
                "coding": [
                  {
                    "system": "http://hl7.org/fhir/questionnaire-item-control",
                    "code": "help",
                    "display": "Help-Button"
                  }
                ],
                "text": "Help-Button"
              }
            }
          ],
          "linkId": "1-help",
          "text": "A description of what is most important to you\nEmergency Information : - Include any essential information that any professional in health and social care should know about the you in any situation, including emergencies.\nOther Information : -This could include : - Values, Spirituality/religion, Ethnicity, Culture, Pets, Goals and aspirations, Meaningful activities including leisure activities, visiting places, sport and exercise, listening to music, employment, education, volunteering",
          "type": "display"
        },
        {
          "linkId": "1.1",
          "text": "Free text description",
          "type": "text",
          "required": false
        },
        {
          "linkId": "1.2",
          "text": "Relevant multimedia file",
          "type": "attachment",
          "required": false,
          "repeats": true
        }
      ]
    },
    {
      "linkId": "2",
      "text": "People who are important to me",
      "type": "group",
      "required": false,
      "item": [
        {
          "extension": [
            {
              "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
              "valueCodeableConcept": {
                "coding": [
                  {
                    "system": "http://hl7.org/fhir/questionnaire-item-control",
                    "code": "help",
                    "display": "Help-Button"
                  }
                ],
                "text": "Help-Button"
              }
            }
          ],
          "linkId": "2-help",
          "text": "Details of who is important to you and why. They could be family members, carers, friends, members of staff etc. Include how you want the people important to you to be engaged and involved in your care and support in both emergency and normal situations. Include how you stay connected to the people important to you. Who should not be contacted or consulted about your care and support and why, if you wish to say",
          "type": "display"
        },
        {
          "linkId": "2.1",
          "text": "Free text description",
          "type": "text",
          "required": false
        },
        {
          "linkId": "2.2",
          "text": "Relevant multimedia file",
          "type": "attachment",
          "required": false,
          "repeats": true
        }
      ]
    },
    {
      "linkId": "3",
      "text": "How I communicate and how to communicate with me",
      "type": "group",
      "required": false,
      "item": [
        {
          "extension": [
            {
              "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
              "valueCodeableConcept": {
                "coding": [
                  {
                    "system": "http://hl7.org/fhir/questionnaire-item-control",
                    "code": "help",
                    "display": "Help-Button"
                  }
                ],
                "text": "Help-Button"
              }
            }
          ],
          "linkId": "3-help",
          "text": "A description of how you communicate normally including any communication aids you use, for example a hearing aid.\nInclude your preferred language of communication, if your first language is not English.\nInclude how you would communicate when you are in pain or distress.\nInclude how you communicate choices.\nInclude how you give feedback or raise a concern.\nInclude how you like to receive information\nDescribe how you would like others to engage and communicate with you, including how you would like to be addressed.",
          "type": "display"
        },
        {
          "linkId": "3.1",
          "text": "Free text description",
          "type": "text",
          "required": false
        },
        {
          "linkId": "3.2",
          "text": "Relevant multimedia file",
          "type": "attachment",
          "required": false,
          "repeats": true
        }
      ]
    },
    {
      "linkId": "4",
      "text": "My wellness (0.3)",
      "type": "group",
      "required": false,
      "item": [
        {
          "extension": [
            {
              "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
              "valueCodeableConcept": {
                "coding": [
                  {
                    "system": "http://hl7.org/fhir/questionnaire-item-control",
                    "code": "help",
                    "display": "Help-Button"
                  }
                ],
                "text": "Help-Button"
              }
            }
          ],
          "linkId": "4-help",
          "text": "A description covering what you are able to do, how you engage with others and how you feel on a typical day through to on a day when you are unwell or really unwell.\nInclude any causes that might result in you becoming unwell and strategies for avoiding or addressing the causes. For example, not drinking enough water could cause constipation.\nInclude any signs that indicate you might be becoming unwell.\nOn a bad day describe what is different about what you are able to do, how you engage with others and how you feel.\nInclude how your everyday life is affected by any medical conditions e.g. dementia and any symptoms e.g. itchiness, cough, pain and how you manage those conditions.\nInclude past health issues or experiences that need to be considered\nInclude your wellbeing and lifestyle goals and aspirations",
          "type": "display"
        },
        {
          "linkId": "4.1",
          "text": "Free text description",
          "type": "text",
          "required": false
        },
        {
          "linkId": "4.2",
          "text": "Relevant multimedia file",
          "type": "attachment",
          "required": false,
          "repeats": true
        }
      ]
    },
    {
      "linkId": "5",
      "text": "Please do and please don't",
      "type": "group",
      "required": false,
      "item": [
        {
          "extension": [
            {
              "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
              "valueCodeableConcept": {
                "coding": [
                  {
                    "system": "http://hl7.org/fhir/questionnaire-item-control",
                    "code": "help",
                    "display": "Help-Button"
                  }
                ],
                "text": "Help-Button"
              }
            }
          ],
          "linkId": "5-help",
          "text": "A description of things you want someone supporting you to do or not to do.\nFor example, this might include: - Talk to me not to my carer, remind me to take my medication, encourage me to wash my hands regularly, explain to me what is happening and why, respond to my communication.\nA description of things you do not want someone supporting for you to do. For example, this might include: - Discussing or asking questions about certain topics, making assumptions about something, providing support when it is not wanted, talking to you in a certain way.",
          "type": "display"
        },
        {
          "linkId": "5.1",
          "text": "Free text description",
          "type": "text",
          "required": false
        },
        {
          "linkId": "5.2",
          "text": "Relevant multimedia file",
          "type": "attachment",
          "required": false,
          "repeats": true
        }
      ]
    },
    {
      "linkId": "6",
      "text": "How and when to support me",
      "type": "group",
      "required": false,
      "item": [
        {
          "extension": [
            {
              "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
              "valueCodeableConcept": {
                "coding": [
                  {
                    "system": "http://hl7.org/fhir/questionnaire-item-control",
                    "code": "help",
                    "display": "Help-Button"
                  }
                ],
                "text": "Help-Button"
              }
            }
          ],
          "linkId": "6-help",
          "text": "A description of how and when you want someone caring for you to support you.\nThis could include support needs in an emergency situation (for example taking blood)\nThis could include support you need to maintain important routines or to carry out particular activities, for example: - Personal care routines, Eating and drinking, Bedtime routines, Taking medications, Moving and transitioning\nThis could also include support needed with:- wearing glasses/hearing aids/false teeth etc, making informed choices or understanding dangers and risks, managing your emotions, moods and behaviours, memory or confusion.\nInclude how your support needs change in different environments. Include any triggers that might result in you needing further support and strategies for avoiding or addressing the triggers. Include how you want the support to be provided.",
          "type": "display"
        },
        {
          "linkId": "6.1",
          "text": "Free text description",
          "type": "text",
          "required": false
        },
        {
          "linkId": "6.2",
          "text": "Relevant multimedia file",
          "type": "attachment",
          "required": false,
          "repeats": true
        }
      ]
    },
    {
      "linkId": "7",
      "text": "Also worth knowing about me",
      "type": "group",
      "required": false,
      "item": [
        {
          "extension": [
            {
              "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
              "valueCodeableConcept": {
                "coding": [
                  {
                    "system": "http://hl7.org/fhir/questionnaire-item-control",
                    "code": "help",
                    "display": "Help-Button"
                  }
                ],
                "text": "Help-Button"
              }
            }
          ],
          "linkId": "7-help",
          "text": "A description of what is also worth knowing about you for people caring or supporting you.\nThis could include a short history of your life (where you have worked, where you lived, important events in your life, important people in your past life).\n This could include a short profile of your current life:- your work / study, your aspirations, your skills, your networks, things you like e.g. particular foods, places, a football team and things you like to talk about, things you dislike\n This could also include any care and support preferences that have not been included elsewhere.",
          "type": "display"
        },
        {
          "linkId": "7.1",
          "text": "Free text description",
          "type": "text",
          "required": false
        },
        {
          "linkId": "7.2",
          "text": "Relevant multimedia file",
          "type": "attachment",
          "required": false,
          "repeats": true
        }
      ]
    },
    {
      "linkId": "8",
      "text": "Supported to write this by",
      "type": "string",
      "required": false,
      "item": [
        {
          "extension": [
            {
              "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
              "valueCodeableConcept": {
                "coding": [
                  {
                    "system": "http://hl7.org/fhir/questionnaire-item-control",
                    "code": "help",
                    "display": "Help-Button"
                  }
                ],
                "text": "Help-Button"
              }
            }
          ],
          "linkId": "8-help",
          "text": "Where relevant, this is a record of name, relationship/role and contact details of the individual who supported the person to write this section e.g. carer, family member, advocate, professional.",
          "type": "display"
        }
      ]
    }
  ]
}