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Data-Dictionary-Adult Social Care Digital Social Care Record_ Minimum Operational Data Standard (MODS)@1.0.7.xlsx

Guidance for CQC registered adult social care providers and their associated suppliers implementing the Adult Social Care Record (MODS) which represents the minimum operational data standard for direct care data in England.

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## Purpose

This document is designed to serve as a comprehensive guide for the implementation of the Adult Social Care Record - Minimum Operational Data Standard (MODS). It aims to detail the updates and modifications in the latest release, ensuring that stakeholders are informed about the essential classes of data encompassed within this standard and the dependencies between it and other standards. The primary intent is to facilitate a smooth adoption and practical application of a standardised data specification across organisations involved in adult social care.

The guidance provided here should be considered in conjunction with the [specific data dictionary for MODS](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification) and the overarching [Conceptual Model for Adult Social Care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/implementation-guidance?page=18). These resources collectively form a robust framework for understanding and applying the data standard effectively.

 ### Aims and objectives of the Adult Social Care Record (MODS)

The primary objective of the Adult Social Care Record (MODS) was to establish a minimum data requirement for recording direct care data by CQC registered adult social care providers and the suppliers in England. Establishment of the Adult Social Care Record (MODS) has been created to support and enable:

**Consistent Data Collection:** Establish a uniform baseline for data gathering by CQC registered adult social care providers in England, aiming to enhance the quality of care delivered.

**Standardised Data Formats:** Promote the use of consistent data structures, acting as a 'common glue' to enable safe data sharing and more cohesive care delivery across different entities.

**Regulatory Compliance and Best Practices:** Reflect regulatory demands and disseminate best practices for data management within the sector.

**Reduction of Administrative Burden:** Minimise repetitive data entry and overlapping reporting obligations, thereby streamlining operational processes.

**Alignment with Broader Standards:** Synchronise with existing standards in the wider health and adult social care systems to avoid inefficiency and redundant efforts ‘reinventing the wheel’.

**Specialised Data Model:** Develop a data model that integrates with current healthcare frameworks but is specifically tailored to the needs of adult social care.

**Support for Technological Advancements:** Foster innovation and the integration of assistive technology within the adult social care sector.

 ### Target Audience

The MODS is primarily developed for adult social care providers and suppliers of information systems in the adult social care sector. This guidance is particularly beneficial for those involved in implementing digital systems in all registered CQC adult social care settings, including integration across various providers. It also serves as a vital resource for care professionals responsible for recording and submitting data into systems using the MODS framework.

Furthermore, MODS is relevant to a diverse range of stakeholders, as outlined in the identified 
[Personas](/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/implementation-guidance?page=13), ensuring a comprehensive understanding and application of the data standard across the sector.

## Background 
The Adult Social Care Record: Minimum Operational Data Standard (MODS) has been designed to establish a suite of interoperable components that, when combined, create a comprehensive digital record for adult social care. These components, or "building blocks," are versatile and can be assembled into specific configurations or included within particular forms, yet they are all unified under an extensive conceptual framework. For instance, an identified need—a fundamental element of the digital social care record—is always connected to an individual. This need might be recognised during various interactions, such as in the process of assessment, within care planning, or through the actual delivery of direct care services.

**Latest Version:**

The Adult Social Care DSCR Minimum Operational Data Standard (MODS V1.0) was formally published 1 April 2025. This iteration is the culmination of an initial discovery phase and the creation of alpha and beta version of MODS. The ongoing development is dedicated to refining the functionality of MODS to ensure optimal performance. The development team is actively engaged in soliciting and incorporating user feedback, with the goal of continuously enhancing MODS in alignment with the insights gained from practical use and research.
All Assured Suppliers to the NHS must conform to the MODS standard by July 2026.
 

### Our Approach

**Related Standards and Programmes of Work:**

<ul>
  <li><a href="https://gpitbjss.atlassian.net/wiki/spaces/DSCR/overview?homepageId=11971330147">Digital Social Care Record (DSCR)</a></li>
  <li><a href="http://www.en13606.org/information.html">ISO 13606</a></li>
  <li><a href="https://contsys.org/page/default">Contsys</a></li>
  <li><a href="https://standards.nhs.uk/published-standards/core-information-standard">Core Information Standard</a></li>
  <li><a href="https://simplifier.net/hl7fhirukcorer4">HL7 FHIR UK CORE</a></li>
  <li><a href="https://termbrowser.nhs.uk/?">SNOMED CT (UK Edition)</a></li>
  <li><a href="https://www.datadictionary.nhs.uk/">NHS Data Dictionary</a></li>
  <li><a href="https://digital.nhs.uk/data-and-information/information-standards/information-standards-and-data-collections-including-extractions/publications-and-notifications/information-standards-notices">ISN Approved Collections</a></li>
  <li><a href="https://openreferraluk.org/">Open Referral</a></li>
  <li><a href="https://standards.esd.org.uk/?">LGA inform</a></li>
  <li><a href="https://coda.io/@savvi/welcome/the-savvi-concept-model-21">SAVVI</a></li>
  <li><a href="https://ckm.openehr.org/ckm/projects/1013.30.77">OpenEHR Social Determinants of Health</a></li>
  <li><a href="https://ckm.openehr.org/ckm/projects/1013.30.39">OpenEHR Social Context Project</a></li>
  <li><a href="https://confluence.hl7.org/display/GRAV/The+Gravity+Project">The Gravity Project - Gravity Project - Confluence</a></li>
  <li><a href="https://confluence.ihtsdotools.org/display/SCCDP/Social+care+content+requirements+project?src=sidebar">SNOMED International Social Care Project</a></li>
</ul>
 

**ISO13606:**

“ISO 13606 is a standard from the International Standardization Organization (ISO), originally designed by the European Committee for Standardization (CEN).

The overall objective of the ISO 13606 standard is to define a rigorous and stable information architecture for communicating part or all of the electronic health record (EHR) of a single subject of care (patient) between EHR systems, or between EHR systems and a centralized EHR data repository. It may also be used for EHR communication between an EHR system and clinical applications or middleware components (such as decision support components) that need to access EHR data, or as the representation of EHR data within a distributed (federated) record system.”

 

Classes of information about the person within the MODS will fall into one of the following categories:

<p>///mermaid
graph TD
accTitle: Classes of information about the person within the MODS will fall into one of the following categories
    accDescr: Imagine a giant digital folder that holds all of a person’s health information in one place. Inside this folder, information is organized a bit like a nesting doll: big folders contain individual records (like a doctor's visit note), and those notes are broken down into smaller sections and specific entries. Each entry then points to the tiny details, such as a specific test result or a single measurement. The system is designed to handle general details about who the person is alongside these specific health stories, making sure that every piece of information—from a broad summary to a single data point—stays connected and easy for healthcare staff to find.
    subgraph EHR_EXTRACT
        DEMOGRAPHIC_DATA[DEMOGRAPHIC DATA]

        FOLDER[FOLDER] --&gt;|sub_folders| FOLDER
        FOLDER -.-&gt;|compositions| COMPOSITION[COMPOSITION]
        
        COMPOSITION --&gt;|content| SECTION[SECTION]
        COMPOSITION --&gt;|content| ENTRY[ENTRY]
        
        SECTION --&gt;|members| SECTION
        SECTION --&gt;|members| ENTRY
        
        ENTRY --&gt;|items| CLUSTER[CLUSTER]
        ENTRY --&gt;|items| ELEMENT[ELEMENT]
        
        CLUSTER --&gt;|parts| CLUSTER
        CLUSTER --&gt;|parts| ELEMENT
        
        ELEMENT --&gt;|value| DATA_VALUE[DATA_VALUE]
    end

</p>
<ul class="details">
<li><a href="">Explain the Classes of information about the person within the MODS diagram</a>
<div>Imagine a giant digital folder that holds all of a person’s health information in one place. Inside this folder, information is organized a bit like a nesting doll: big folders contain individual records (like a doctor's visit note), and those notes are broken down into smaller sections and specific entries. Each entry then points to the tiny details, such as a specific test result or a single measurement. The system is designed to handle general details about who the person is alongside these specific health stories, making sure that every piece of information—from a broad summary to a single data point—stays connected and easy for healthcare staff to find.</div>
</li>
</ul>


**EHR_EXTRACT:** The top-level container of part or all of the health and adult social care record of a single subject of care, for communication between an EHR Provider system and an EHR Recipient. 
**FOLDER:** The high level organisation within a health and adult social care record, dividing it into compartments relating to care provided for a single condition, by a clinical team or institution, or over a fixed time period such as an episode of care. Examples of FOLDER are Diabetes care, Schizophrenia, Cholecystectomy, Paediatrics, St Mungo’s Hospital, GP Folder, Episodes 2000-2001, Italy. 
**COMPOSITION:** The set of information committed to one health and adult social care record as a result of a clinical encounter or a record documentation session. Examples of COMPOSITION are Progress note, Laboratory test result form, Radiology report, Referral letter, Clinic visit, Clinic letter, Discharge summary, Functional health assessment, Diabetes review. 
**SECTION:** EHR data within a COMPOSITION that belongs under one care heading, usually reflecting the flow of information gathering during a care encounter, or structured for the benefit of future human readership. Examples of SECTION are Reason for encounter, Past history, Family History, Allergy information, Subjective symptoms, Objective findings, Analysis, Plan, Treatment, Diet, Posture, Abdominal examination, Retinal examination. 
**ENTRY:** The information recorded in a health and adult social care record as a result of one clinical action, one observation, one clinical interpretation, or an intention. This is also known as a clinical statement. Examples of ENTRY are a symptom, an observation, one test result, a prescribed drug, an allergy reaction, a diagnosis, a differential diagnosis, a differential white cell count, blood pressure measurement. 
**CLUSTER:** The means of organising nested multi-part data structures such as time series, list or tables. Examples of CLUSTER are Audiogram results, electro-encephalogram interpretation, weighted differential diagnoses. 
**ELEMENT:** The leaf node of the health and adult social care record hierarchy, containing a single data value. Each ELEMENT contains data of a particular Data Type. Examples of ELEMENT are Systolic blood pressure, heart rate, drug name, symptom, body weight.
 

For more information on that standards please see 
[ISO 13606 Standard - EHR Interoperability](http://www.en13606.org/information.html)

## Requirements and use Cases

The NHS Transformation Directorate's Digitising Social Care (DiSC) Programme has introduced an Assured Supplier List to support Adult Social Care providers in England in selecting from a verified roster of Digital Social Care Records (DSCR) Solutions. These solutions have been integrated through the Dynamic Purchasing System (DPS), with its specifications transformed into Capabilities and Standards to align with the Digital Care Services (DCS) Framework.

The Adult Social Care Record (MODS) is a critical component of these data standards. It encompasses data classes and data elements that outline the requirements for how information should be recorded from individuals receiving care from a CQC regulated social care service.

In the process of establishing the MODS, a series of use cases and requirements were identified:

* [Use case 1: Consistency of care to an individual when a temporary worker needs to step in](/published-standards/adult-social-care-record-mods/implementation-guidance?page=5#)
* [Use case 2: Communicating an individual's care needs between local authority and care provider at the point of commissioning](/published-standards/adult-social-care-record-mods/implementation-guidance?page=6#)
* [Use case 3: Consistency of care and recording across a multi-disciplinary team](/published-standards/adult-social-care-record-mods/implementation-guidance?page=7#)
* [Use case 4: Providing consistent support in hospital and at home for an individual with an existing care plan](/published-standards/adult-social-care-record-mods/implementation-guidance?page=8#)
* [Use case 5: Implementing a new social care system](/published-standards/adult-social-care-record-mods/implementation-guidance?page=9#)
* [Use case 6: Care provider moving to a digital system](/published-standards/adult-social-care-record-mods/implementation-guidance?page=10#)
* [Use case 7: Sharing elements of care planning information across many systems – components or "building blocks" of care plan](/published-standards/adult-social-care-record-mods/implementation-guidance?page=11#)
* [Use case 8: DHSC receiving information from local authorities and care providers](/published-standards/adult-social-care-record-mods/implementation-guidance?page=12#)
* [Personas](/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/implementation-guidance?page=13)
* [Additional use cases](/published-standards/adult-social-care-record-mods/implementation-guidance?page=14#)

### Use case 1: Consistency of care to an individual when a temporary worker needs to step in

####Scenario:
Mr. Green ([Subject of care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685)) has been living in a care home ([Care Organisation](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=465255)) for several years. He is a very social person ([About me](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=463962#), [Strengths](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464142), [Need](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=465037)) and is often in the communal rooms such as the dining room ([Preferences](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464123)). Also, he likes to participate in activities such as singing and painting ([Preferences](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464123), [Service](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464057)). Mr. Green is somebody who likes to have a lot of structure in his life ([Preferences](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464123)).

He is normally assisted by Nurse Assistant Emily ([Care worker](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=465857) who [provides care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=465819#) for Mr. Green and is flagged as a [key worker](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=463619)), but she is on leave for a week and her shifts are being covered by an agency worker, Eliza ([Care worker](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=465857)). Eliza is an experienced care worker but has never worked in this care home or met any of the residents. Before starting work this morning she spent a few minutes going over the residents' records (Adult Social Care Record) to find out a little about them.

Today, Mr. Green ([Subject of care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685)) woke up at 8 o’clock. Nurse assistant Eliza reviewed her tasks ([Task](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464055)) and assisted Mr. Green with a shower ([Action](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=584590)) and helped him to go to the toilet ([Action](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=584590)).

By himself, he walked to the dining room where he ate two eggs and a roll and drank a cup of coffee. He was sitting next to Mr. Brown where he normally sits. After that, he read the daily newspaper.

At 9 o’clock nurse Eva ([Care worker](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=465857)) gave him his medication ([Medication](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464052), [Action](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=584590)), which he took with a glass of water.

At 10 o’clock Mr. Green ([Subject of care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685)) was picked up ([Action](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=584590)) by the activity well-being facilitator Mahsa ([Care worker](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=465857)) so that Mr. Green could participate in the choir group ([Service](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464057)). He was in a good mood and looked as if he was having a good time with the other residents ([Outcome](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=465118#)). At 12 o’clock he went for lunch in the dining room where he ate some soup and a sandwich. After that he went for an afternoon nap in his room.

#### Goal: 
Monitoring the assistance of Mr. Green with his daily life in a care home. Take care of him and help him with washing himself, ensuring he gets his daily medication, food and drinks and that he goes to the activities that he enjoys provided by the care home.

#### Assumptions: 
Retaining patient data roughly consists of three steps: Recording (1), sharing it with colleagues (2) and sharing it with the recipient of care (3). For this process to run smoothly, it is important that the data is understandable and reusable for everyone and can be monitored over time to see changes. In this use case, the focus is on a recipient of care in a care home, so it is information that carers and activity well-being facilitators capture in the daily life of Mr. Green. Every individual and each day are different so the information can be different, it totally depends on the recipient of care and the care needs somebody has at the time. Also, this sharing of information is between carers and activity providers, but it can also be that a transfer message has to be shared multidisciplinary for example between a carer and a doctor. In all situations the information needs to be easily comparable with days, weeks or months before to understand changes in the individual’s state.

#### Process breakdown:
Note time when Mr. Green was awake and wanted to have a shower ([Daily Living](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=466369#))
Note which food Mr. Green ate and what he was drinking ([Daily Living](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=466369#))
Note if and which medication Mr. Green took ([Medication](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464052), [Action](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=584590))
Note in which activities Mr. Green was active ([Activities](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=584589))
Note which care worker helped the recipient of care ([Care worker](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=465857))
Note how his day schedule looked ([Activities](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=584589))
Note in which social (group) activities he was active ([Activities](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=584589))
Note how his mood and communication was ([Outcome](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=465118#))
Note how much sleep he had ([Daily Living](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=466369#))
Note if any markable changes occurred compared with the situation before ([Outcome](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=465118#))
These data points are the core information about Mr. Green's daily life. MODS contributes to Eliza's ability to care for him and the data she has access to and populates could be recorded using MODS.

### Use case 2: Communicating an individual's care needs between local authority and care provider at the point of commissioning

#### Scenario:
Mr. Bodat ([Subject of care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685)) is a 73-year-old man ([Date of birth](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=463585)), a widower ([Marital status](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464126)).

He was quite healthy until recently but is getting more and more health complaints ([Problems](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464010&amp;elementId=%22%22#), [Needs](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463702)) and social care needs ([Needs](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463702)). He lives in a complex home situation (Accommodation status, Environment, Circumstances).

For a week, he cannot not really move due to recent foot problems - he lives on the third floor of an old apartment building with only steep stairs ([Problems](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464010&amp;elementId=%22%22#), [Needs](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463702)). His days seem to become lonelier and lonelier, and neighbours from downstairs now rarely see him ([Social circumstances](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463989), [Needs](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463702)). One neighbour ([Personal contact](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463950)) talked to a social care youth worker ([Care worker](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463617)) he met accidentally and mentioned the situation. The youth worker ([Care worker](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463617)) offered to refer ([Referral](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464056&amp;elementId=%22%22#)) Mr. Bodat ([Subject of care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685)) to Adult Social Care for an assessment of his needs ([Care needs assessment](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=463713)).

#### Goal: 
To assess Mr. Bodat’s eligible care and support needs, and to commission a package of care which will meet those needs and allow him to continue living independently in his own home.

#### Assumptions: 
The system needs to reconcile Mr. Bodat's eligible outcomes, as assessed under the Care Act, with his desired outcomes in terms of his ability to live a fulfilling life. The assessment may identify non-eligible needs which Mr. Bodat nevertheless would like to have met. The care provider and Mr. Bodat may agree on a slightly different set of priorities and outcomes for the care to be provided versus the care funded by the local authority. However, since Mr. Bodat cannot contribute any first-party top-ups to the cost of his care, the costs need to remain within the authority's funding envelope.

#### Process breakdown:
Youth care worker acknowledges he is not responsible for care, but makes referral to Social Care for assessment ([Referral](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464056&amp;elementId=%22%22#))
Emma, a Social Worker ([Care worker](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463617)), visits Mr. Bodat ([Subject of care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685)) and carries out a Care Act needs assessment ([Care needs assessment](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=463713))
Emma assesses Mr. Bodat's wellbeing, health, selfcare abilities and social situation, and determines that he is eligible for care to be provided by the local authority ([Care needs assessment](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=463713))
Caroline, a finance officer, visits Mr. Bodat to carry out a financial assessment to determine what if anything he will need to pay towards the cost of his care. His income and savings are below the relevant thresholds and the local authority will fund the full cost of meeting his eligible care needs (Out of scope)
Caroline also makes an appointment for Mr. Bodat to speak to the Benefits Advice team at the council, as she believes he is eligible for more disability benefits than he is currently receiving due to his declining health (Out of scope)
In parallel, Emma ([Care worker](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463617)) completes a care plan ([Care and support plan](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464165)) covering Mr. Bodat's ([Subject of care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685)) eligible needs ([Needs](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463702)). This includes a base unit ([Device](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464570) providing medication reminders and a Lifeline alarm ([Device](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464570)), and two home visits a day ([Task](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464055)) to meet his personal care needs. Emma also puts Mr. Bodat in contact with a community group who offer a befriending service ([Service](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464057)), can help him get online ([Task](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464055)), and can do a weekly shop for him ([Task](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464055)).
Once the care plan ([Care and support plan](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464165)) has been agreed ([Agreed with person or legitimate representative](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=464567)) with Mr Bodat ([Subject of care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685)), Emma ([Care worker](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463617)) passes it to the Brokerage team to procure the home care elements (Out of scope)
The package is picked up by a local provider ([Social Care Provider](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=464567)), who sends Sue ([Care worker](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463617)) to visit Mr. Bodat ([Subject of care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685)) to get to know him and see what his situation is really like. Sue confirms the information received from the local authority, captures further details of his day-to-day needs ([Needs](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463702)) and completes the "About Me" record ([About me](https://standards.nhs.uk/published-standards/about-me)).
Sue is able to gauge for herself, as she talks to Mr. Bodat ([Subject of care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685)), that the information on the record is accurate in terms of his health, mobility, mental capacity and cognition ([Needs](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463702))(Review)
Mr. Bodat ([Subject of care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685)) tells Sue ([Care worker](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463617)) about his regular medications ([Medication](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464052)) - although he can administer them himself, he worries about forgetting to take his medication and about getting his repeat prescriptions (Risk)
Sue ([Care worker](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463617)) returns to the office and updates the records. She discusses Mr. Bodat's ([Subject of care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685)) care needs ([Needs](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463702)) with her manager and they agree a more detailed care plan ([Care and support plan](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464165)) showing how his needs will be met within the time funded by the local authority. The manager assigns another worker, Andi , to be Mr. Bodat's care worker ([Care worker](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463617))

### Use case 3: Consistency of care and recording across a multi-disciplinary team

An individual's daily care involves a diverse group of healthcare and social care practitioners—including GPs, district nurses, social workers, care providers, care workers, social prescribers, local authority call handlers, among others. While these care workers do not function as a unified multi-disciplinary team, they require access to comprehensible and precise records. These records must be articulated in a vernacular that merges clinical precision with everyday language, enabling these varied practitioners to document and exchange information effectively. This collaborative approach is essential to inform continued care and support the individual in leading their desired lifestyle.

#### Scenario:
Mrs Smith ([Subject of care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685)) lives alone ([Household composition](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464126)) but due to mobility issues ([Needs](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463702)) she is unable to leave her home without support ([Need](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463702)) and requires assistance with dressing ([Need](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463702)) and personal care ([Need](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463702)). She has dementia ([Need](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463702)) so can give inconsistent responses regarding her abilities and medication ([Risk](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463973)).
Jane ([Care worker](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463617)), an experienced care worker, visits (Tasks) Mrs Smith ([Subject of care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685)) at 10am. When she arrives she wakes ([Action](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=584590)) Mrs Smith ([Subject of care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685)) and administers her medication ([Medication](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464052), Action). Mrs Smith ([Subject of care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685)) complains of a headache (Problem) so additional medication is given ([Medication](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464052), Action). Mrs Smith ([Subject of care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685)) is supported to get out of bed ([Action](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=584590)) , shower ([Action](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=584590)) and get dressed ([Action](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=584590)). Jane cooks her breakfast ([Action](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=584590)) and then leaves.
At midday, Alan ([Care worker](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463617)), a new social worker, visits to review (Review) Mrs Smith's care plan ([Care and support plan](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464165)). Mrs Smith's son, Robert ([Personal contact](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463950)), also arrives to take part in this meeting. During the meeting Mrs Smith ([Subject of care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685)) says that she has no mobility issues and can use the toilet independently. Robert ([Personal contact](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463950)), challenges this and explains that Mrs Smith ([Subject of care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685)) has carers twice a day to help with this. Mrs Smith ([Subject of care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685)) is confused about her care needs and insists that she does not need support ([Risk](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463973)). She also asks for additional medication for a headache. Robert gives her this medication ([Medication](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464052), Action).
Sophie ([Care worker](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463617)), a new care worker who has recently joined the agency, arrives to visit (Tasks) Mrs Smith ([Subject of care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685)) in the evening. When she arrives Mrs Smith ([Subject of care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685)) advises that she does not need any help going to the toilet and has already taken her medication. Mrs Smith ([Subject of care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685)) insists that she does not need support so attempts to get to the bathroom by herself and falls ([Incident](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463988)).
Sophie ([Care worker](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463617)) calls an Ambulance as Mrs Smith ([Subject of care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685)) hits her head when falling and she is taken to A&amp;E ([Admission details](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464147)). Sophie ([Care worker](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463617)) is unsure what medication ([Medication](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464052)) Mrs Smith has taken today and the details of her support needs ([Need](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463702), [Risk](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463973)). When Mrs Smith ([Subject of care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685)) arrives at A&amp;E she tells the doctor and nurses that she lives independently and does not need support with personal care. She also tells them that she has not taken any medication today.

#### Goal: 
Support Mrs Smith to continue to live in her own home by providing consistent care and support. Sharing information with all other professionals and family carers to safeguard and support her, including preventing falls and monitoring medication administered.

#### Assumptions: 
In this use case, the recipient of care lives alone but has dementia so may give inconsistent responses about her care and support needs and medication. Providing clear and consistent information/records about medication administered, Mrs Smith's mobility and personal care needs and the likelihood of confusion due to dementia is essential. This information should be shared with all professionals and family members regularly so they can support Mrs Smith appropriately. If this information is not available to all professionals supporting Mrs Smith, then she may injure herself, receive duplicate medication or overstate her abilities.

#### Process breakdown:
Record the time Mrs Smith was woken ([Action](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=584590))
Record the time Mrs Smith took routine medication ([Medication](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464052), [Action](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=584590))
Record the additional medication administered ([Medication](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464052), [Action](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=584590))
Record support required for personal care ([Care and support plan](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464165))
Record food provided ([Action](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=584590))
Record Risks that Mrs Smith get’s confused and sometimes forgets that medication has been administered and overstates her abilities ([Risk](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463973))
Record fall and procedure followed ([Incident](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463988)).
Record Hospital admission details ([Admission details](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464147))
Record Hospital records of medication administered and support required ([Medication](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464052), [Action](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=584590))

### Use case 4: Providing consistent support in hospital and at home for an individual with an existing care plan

Teams responsible for hospital admissions and discharges understand the existing care plans and ensure that they communicate the requisite care details to care providers upon a patient's discharge.

#### Scenario:
James ([Subject of care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685)) has a learning disability ([Reasonable adjustment](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=465648), Impairment, [Needs](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463702)) and lives in supported living (Accommodation status).
James ([Subject of care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685)) has not been well and was admitted to hospital for 48 hours ([Admission details](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464147)).
When James ([Subject of care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685)) arrived with his care worker ([Care worker](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463617)), they explained to the nurse in A&amp;E that he had a learning disability ([Reasonable adjustment](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=465648)) and would need information explained to him clearly ([Need](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463702)) and any documents would need to be in an easy read format ([Need](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463702)). They did not bring along a copy of James' ([Care and support plan](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464165)) which explains the support he needs with dressing and going to the bathroom etc.
When James ([Subject of care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685)) was admitted to the ward, his care worker ([Care worker](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463617)) explained to the ward nurse ([Care worker](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463617)) that he had a learning disability and would need additional support ([Need](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463702)). His care worker then had to leave.
During his stay at hospital James ([Subject of care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685)) struggled to understand what the doctors and nurses were explaining to him and found it difficult to ask for help. When James was discharged ([Discharge details](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=465031)), a different care worker ([Care worker](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463617)) came to collect him, James ([Subject of care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685)) was very distressed ([Outcome](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=465118)). The nurse ([Care worker](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463617)) gave James' care worker ([Care worker](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463617)) a copy of his discharge papers ([Discharge details](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=465031)) and explained the extra support ([Need](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463702)) and medication ([Medication](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464052)) James ([Subject of care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685)) would need over the next week.
When they arrived home, James' care worker ([Care worker](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463617)) showed the manager ([Care worker](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463617)) his discharge papers ([Discharge details](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=465031)) and they were filed but the information about James' ([Subject of care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685)) additional support ([Need](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463702)) and medication ([Medication](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464052)) this week were not shared with the rest of the team.

#### Goal: 
Everyone who cares for James in hospital is able to access a digital copy of his care plan so they are aware of his needs and able to provide him with the correct level of support. When he is discharged from hospital, his after care is incorporated into his care plan and the necessary information from his hospital stay is shared with his family carers and care provider staff.

#### Assumptions: 
As James has a learning disability, he may struggle to understand some of the information provided at the hospital, need extra support and a copy of his care plan should be shared with hospital staff. The Red Bag Scheme could be beneficial in this scenario.
Details of additional support needs noted by nurses - but unable to access a digital copy of care plan, no paper copy provided
Paper copy of the documents filed by the care provider but not shared with all staff who may support James over the next week
By having a clear digital shared care record with James's care and support needs available to all NHS staff would enable them to support James better. When he is discharged, the additional support needs from his hospital stay could be added to this digital record and then this could be accessed by all care staff at James' supported living accommodation. This would ensure consistent care and support in both settings.

#### Process breakdown:
Hospital admission ([Admission details](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464147))
Additional support needs noted by nurses ([Needs](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463702), Care and support plan)
Hospital records maintained and shared ([Needs](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463702), [Medication](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464052))
Discharge papers provided to care worker ([Discharge details](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=465031))

### Use case 5: Implementing a new social care system

Enabling easier implementation of new adult social care IT systems.

#### Scenario:
A London council are in the process of implementing a new social care IT (DSCR) system.
They need to be confident that all potential suppliers have the same understanding of the requirements set out in the tender documentation, so that the tenders they receive are directly comparable and are fit for purpose.
Each [Subject of care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685) (person’s) record needs to capture their [demographic information](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463586), [alerts](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=464180), [care and support needs](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464165), family support network, [professionals involved](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=464564) etc.
Then they need to tailor the workflow to meet the needs of their staff for accurate and efficient recording, whilst also capturing all the essential information for statutory returns and future CQC regulatory requirements.
They also need to consider integrations like connected care health systems to ensure they are sharing data securely, in the correct format and regularly to maintain an accurate DSCR
To ensure they have captured all this information, are using the most up to date datasets and terminology, they refer to the Adult Social Care (ASC) Data Catalogue and MODS.

#### Goal: 
Implement an effective, accurate and efficient adult social care IT (DSCR) solution which meets the needs of their staff, captures all statutory information and promotes effective support and safeguarding of vulnerable adults.
Implementing a system with standardised datasets and terminology will lead to more effective interoperability between health, adult social care and care providers.
Having agreed a MODS, it will make it easier to switch between systems and given agreed areas that should be covered by the MODS should enable system suppliers to have more consistent processes across systems as they all need to meet the same requirements. This should reduce the training overhead for staff and will improve safeguarding as recording standards should be easier to maintain.

#### Assumptions: 
The LA will have legacy data from whatever system was in use previously. It should be possible for this data to be able to be incorporated into the new system so that there is one case history for each service user. Any previous documents/attachments should be able to be transferred across so that they give the appropriate context to the service user's information. This is not in scope for this programme of work.
It should be possible for information fields to be mapped so that the legacy data can be straightforwardly imported into the new system and will sit under the appropriate headings/sections of that system (e.g. involvements, contact numbers, hazards etc). LA Case Management systems (CMS) out of scope.

#### Process breakdown:
Procure a adult social care system that meets the needs of the organisation and supports efficient recording of regulatory requirements
Tailor the system to meet the needs of the staff using the system and the people receiving care
Consider which data tables are in the system and to which of the MODS do these link
Import legacy data into the new system and be able to access it (view, edit, update) in the correct screens/areas of that system
Import any associated documentation or plans into the new system and be able to access them in the appropriate areas of that system
Work with health and care providers to ensure the systems can integrate for future sustainability
Provide training to all staff to ensure they can use the system to maintain accurate records for direct care

### Use case 6: Care provider moving to a digital system

As care providers move to digital systems by 2025, this will enable easier transfer of routine info to local authorities.

#### Scenario:
A CQC registered care adult social care provider ([Social Care Provider](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=464567)) is in the process of implementing digital social care records to improve the support they can provider for their recipients of care ([Subject of care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685)) and their joined up working with other services.
Utilising the [MODS](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods) on the ASC Data Catalogue has provided them with guidance around the minimum operational data standard so they are confident that they will meet all regulatory requirements and the data they will be sharing will be fully aligned with other services. They have then been able to work with the Digitising Social Care Programme to tailor this to their needs and use this opportunity to improve their recording practices.
By having access to up to date health and adult social care information, they can create better packages of support for their recipients of care ([Subject of care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685)). As a care provider ([Social Care Provider](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=464567)), they have valuable insight into the recipient of care's day to day activities and support needs ([Needs](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463702)) so they can also share this valuable data with the other services to provide more consistent support in all settings.

#### Goal: 
The Digitising Social Care Records Programme is aiming for 80% all CQC-registered adult social care providers to have access to a digital social care record that can interoperate with a local Shared Care Record by March 2025.
These records will play a vital role in joining up health and adult social care, freeing up time spent for the workforce across health and adult social care on administrative tasks whilst equipping them with the information they need to deliver care. They are the platform on which other remote care tools can integrate and can enable the greater personalisation of care planning that focuses on the individual.
Assumptions: 
The care provider will have enough networked equipment available (e.g. tablets, pads, laptops etc) for their staff to be able to capture and access key information once that information has been put into a digital system.
The workforce will be sufficiently trained and IT-capable to be able to access the relevant system(s) to be able to view, edit and update key information on their service users.

#### Process breakdown:
Procure a digital system that meets the needs of the organisation and supports efficient recording of statutory and regulatory requirements
Tailor the system to meet the needs of the care provider and people receiving care.
Work with health and adult social care suppliers and providers to ensure the systems can integrate.
Provide training to all staff to ensure they can use the system to maintain accurate records

### Use case 7: Sharing elements of care planning information across many systems – components or "building blocks" of care plan

This use case does not follow the structure of the others, as there are multiple scenarios involved. Instead we have identified a range of user needs which combine to describe the benefits of a properly structured record.

<table>
  <caption>
MODS user needs and data source mapping across care, health, social work, and system roles
  </caption>
  <thead>
<tr>
  <th>As a…</th>
  <th>I need…</th>
  <th>So that…</th>
  <th>MODS data sources</th>
  <th>Other data sources</th>
</tr>
  </thead>
  <tbody>
<tr>
  <td>Person receiving care</td>
  <td>
To tell people about my care and support needs (including any changes to what I need)
once and once only
  </td>
  <td>
(a) I don't have to keep repeating myself to all the different professionals involved in my life<br>
(b) my care and support can adapt to meet my changing needs
  </td>
  <td>
<a href="/published-standards/about-me">About Me</a><br>
<a href="/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463622">Observations</a> including but not limited to<br>
<a href="/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463702">Needs</a>, <a href="/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463973">Risks</a>, <a href="/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464122">Wishes</a>, <a href="/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464123">Preferences</a>, <a href="/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464142">Strengths</a>
  </td>
  <td></td>
</tr>

<tr>
  <td>Person receiving care</td>
  <td>
Everyone involved in my care and support to have access to comprehensive and up-to-date
information about my care and support needs
  </td>
  <td>
I get the right level and type of care and support at the right time
  </td>
  <td>
<a href="/published-standards/about-me">About Me</a><br>
<a href="/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463622">Observations</a> such as<br>
<a href="/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463702">Needs</a>, <a href="/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463973">Risks</a>, <a href="/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464122">Wishes</a>, <a href="/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464123">Preferences</a>, <a href="/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464142">Strengths</a><br><br>
Problems<br>
Medication management<br>
Allergies and adverse reactions
  </td>
  <td></td>
</tr>

<tr>
  <td>Care actor</td>
  <td>
My involvement as a carer to be included in the Digital Social Care Record
  </td>
  <td>
Professionals are aware of the role I play in caring for/supporting the individual,
and are able to involve me appropriately throughout the individual's care journey
  </td>
  <td><a href="/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463617">Carers</a></td>
  <td></td>
</tr>

<tr>
  <td>Data SME</td>
  <td>
I need to understand the definitions, formats and processes used to collect data
from various organisations and people and ensure that is consistent
  </td>
  <td>
I can provide aggregate data that is statistically valid, consistent over time,
and fit for a wide range of purposes
  </td>
  <td></td>
  <td></td>
</tr>

<tr>
  <td>Data SME</td>
  <td>
Client/person level data to align with existing data sources about individuals,
eg PDS, GP Connect
  </td>
  <td>
To avoid duplication of records, so that aggregate data gives a more accurate picture
across the whole population
  </td>
  <td>MODS</td>
  <td>
PDS<br>
GP Connect
  </td>
</tr>

<tr>
  <td>Operational SME (care provider)</td>
  <td>
My records to be populated with accurate, up-to-date data about health conditions,
allergies and adverse reactions, prescriptions, etc from the GP's records; and this
data to be updated in real time if it changes
  </td>
  <td>
(a) I can ensure the person receiving care’s day-to-day health needs are being met correctly<br>
(b) I don't need to re-create/re-enter data that is already held digitally
  </td>
  <td>
<a href="/published-standards/about-me">About Me</a><br>
<a href="/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463622">Observations</a> including but not limited to<br>
<a href="/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463702">Needs</a>, <a href="/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463973">Risks</a>, <a href="/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464122">Wishes</a>, <a href="/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464123">Preferences</a>, <a href="/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464142">Strengths</a>
  </td>
  <td>GP Connect</td>
</tr>

<tr>
  <td>Operational SME (care provider)</td>
  <td>
Confidence that I have a legitimate reason to hold/access all the data held within the DSCR/MODS
  </td>
  <td>I am fully compliant with the GDPR</td>
  <td></td>
  <td></td>
</tr>

<tr>
  <td>Operational SME (care provider)</td>
  <td>
New care and support packages arriving from the local authority to contain as much detail as possible
about the individual's care and support needs, health conditions (including cognitive and sensory
impairments) and desired outcomes
  </td>
  <td>
I don't need to repeat any aspects of the needs assessment process which others have already undertaken
  </td>
  <td>
<a href="/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463622">Observations</a> including but not limited to<br>
<a href="/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463702">Needs</a>, <a href="/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463973">Risks</a>, <a href="/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464122">Wishes</a>, <a href="/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464123">Preferences</a>, <a href="/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464142">Strengths</a>
  </td>
  <td>
Care Act eligibility assessment<br>
LA care and support plan<br>
GP Connect
  </td>
</tr>

<tr>
  <td>Operational SME (care provider)</td>
  <td>
New care and support packages arriving from the local authority to include a clear statement of the care
and support being commissioned, including time and cost
  </td>
  <td>
I can ensure the care and support I provide is in line with the funding available for it
  </td>
  <td></td>
  <td>
LA care and support plan<br>
LA funding – time and budget
  </td>
</tr>

<tr>
  <td>Operational SME (care provider)</td>
  <td>To locate data sources about indicators/metrics</td>
  <td>
I can incorporate data collection needs into my internal working processes as efficiently as possible
  </td>
  <td></td>
  <td>
NHS Digital<br>
CQC<br>
Skills for Care
  </td>
</tr>

<tr>
  <td>Operational SME (care provider)</td>
  <td>
Confidence that the DSCR/MODS is fully aligned with statutory/regulatory requirements
  </td>
  <td>
I can be certain that by adopting MODS I am meeting all these requirements
  </td>
  <td>MODS</td>
  <td>
Primary and secondary legislation<br>
CQC guidance<br>
NICE guidance
  </td>
</tr>

<tr>
  <td>Operational SME (care provider)</td>
  <td>
To be consulted/informed about changes to statutory requirements, data standards,
data gathering requirements, registration requirements etc
  </td>
  <td>
I can be fully prepared for changes which will impact on the way I provide care and support
and/or capture data
  </td>
  <td></td>
  <td></td>
</tr>

<tr>
  <td>Operational SME (care provider)</td>
  <td>Access to standard national datasets and data standards</td>
  <td>
I can review/compare them against the data I capture in my own systems
  </td>
  <td></td>
  <td></td>
</tr>

<tr>
  <td>Operational SME (care provider)</td>
  <td>
To be notified when someone I provide domiciliary care for is admitted to hospital
  </td>
  <td>I do not have to make unnecessary visits</td>
  <td></td>
  <td>Hospital systems</td>
</tr>

<tr>
  <td>Operational SME (health)</td>
  <td>
Clear and accurate information about the care and support needs of a person with sensory or
cognitive impairment, learning disabilities and/or mental health needs when they are admitted to hospital
  </td>
  <td>
We can communicate with them effectively and take account of their needs in the way we care for them in hospital
  </td>
  <td>
<a href="/published-standards/about-me">About Me</a><br>
<a href="/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463622">Observations</a> including but not limited to<br>
<a href="/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463702">Needs</a>, <a href="/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463973">Risks</a>, <a href="/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464122">Wishes</a>, <a href="/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464123">Preferences</a>, <a href="/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464142">Strengths</a><br>
<a href="/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464165">Care and support plan</a><br>
<a href="/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463617">Carers</a>
  </td>
  <td>About Me</td>
</tr>

<tr>
  <td>Operational SME (health)</td>
  <td>
Clear and accurate information about the care and support arrangements available at home
when someone is discharged from hospital
  </td>
  <td>
We know if it is safe and appropriate to discharge the individual back home
  </td>
  <td>
Care and support plan<br>
Carers
  </td>
  <td></td>
</tr>

<tr>
  <td>Operational SME (social work)</td>
  <td>
Data from care providers and TEC systems at an appropriate level of detail about the
day-to-day care and support provided to an individual and the outcomes being achieved
  </td>
  <td>
(a) Contribute to the annual review of the individual's care and support plan<br>
(b) Flag any significant changes in care and support needs<br>
(c) Ensure commissioning meets current and future demand
  </td>
  <td>
<a href="/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464011">Instructions</a><br>
<a href="/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464012&gt;Activities&lt;/a&gt;&lt;br&gt;
&lt;a href=">Actions</a><br>
<a href="/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=464180">Alert</a><br>
<a href="/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=465118">Outcome</a>
  </td>
  <td>
TEC data<br>
Day-to-day care record<br>
Hospital admissions/discharges<br>
Changes in care and support needs
  </td>
</tr>

<tr>
  <td>
Operational SME (social work)<br>
Operational SME (care provider)
  </td>
  <td>
To record data once in the system, ensure it is complete and accurate, and be confident
that it will reach everyone else who needs to see it
  </td>
  <td>
To reduce the time pressure of constantly re-entering data and responding to requests
for routine information
  </td>
  <td>MODS</td>
  <td></td>
</tr>

<tr>
  <td>System SME (system administrator)</td>
  <td>
To be consulted/informed about changes to statutory requirements, data standards,
data gathering requirements, registration requirements etc
  </td>
  <td>
I can be fully prepared for changes which will impact on the way I capture data
  </td>
  <td></td>
  <td></td>
</tr>

<tr>
  <td>System SME (system supplier)</td>
  <td>To locate data sources about indicators/metrics</td>
  <td>
I can ensure that data is captured correctly to auto-populate the statutory returns
required of my clients
  </td>
  <td>MODS</td>
  <td></td>
</tr>

<tr>
  <td>System SME (system supplier)</td>
  <td>To locate person-specific data sources</td>
  <td>
I can create the functionality to import person-specific data from reliable and
trustworthy sources to save double-entry and data quality issues
  </td>
  <td></td>
  <td>
Data Catalogue<br>
PDS<br>
GP Connect
  </td>
</tr>
  </tbody>
</table>

### Use case 8: DHSC receiving information from local authorities and care providers

#### Use case:
DHSC able to receive management information from all local authorities and adult social care providers which uses agreed, understood and shared terminology

#### Scenario:
* The Department of Health and Social Care (DHSC) are working to improve the way they collect management information from local authorities and adult social care providers. They have noticed that the information they are receiving is often inconsistent and during sessions to analyse the data with local authorities and adult social care providers they discussed the data discrepancies. This highlighted different understanding of the terms being used differently by local authorities and adult social care providers, for example 'carer' and other terms like 'personal budget' and ‘needs assessment’ had varying definitions.

* A glossary of adult social care terminology with agreed definitions would help to resolve this issue and provide more consistent data for both health and adult social care, supporting improved secure information sharing available at the right time for the right person in the right place for direct care.

#### Goal: 
DHSC receive management information in a consistent format with agreed and understood terminology to ensure information is reported consistently. To do this, an agreed glossary of terms and definitions should be created in partnership with health, care providers and local authorities.

#### Assumptions: 
Throughout the discovery phase of this project we have identified a number of words/terms that are used inconsistently by different services or have multiple meanings. Finding consistent definitions can be difficult and often each authority has a slightly different definitions for a term, a good example is personal budget. Having a defined and consistent terminology that all local authorities and care providers use would reduce the confusion and inconsistency.

### Additional use cases

Additional use cases, prioritised and mapped to care actors:

<table>
<thead>
<tr>
<th>Category</th>
<th>Use case</th>
<th>Priority (derived from stakeholder survey)</th>
<th>LA ASC</th>
<th>Care recipients</th>
<th>Carers</th>
<th>Care providers</th>
<th>NHS</th>
<th>PH</th>
<th>C&amp;F</th>
<th>DHSC</th>
<th>Software suppliers</th>
</tr>
</thead>
<tbody>
<tr>
<td>Individual</td>
<td>Multiple clinicians/professionals/carers involved in an individual's day-to-day life (GP, District Nurse, social worker, care provider, care worker, social prescriber, local authority call handler, others), not operating as part of a multi-disciplinary team, but needing to access clear and accurate records - in a language that bridges the gap between clinical and everyday terminology - and capture/share information to inform ongoing care delivery and to help the person live the life they want to.</td>
<td>3.97</td>
<td>Y</td>
<td>Y</td>
<td>Y</td>
<td>Y</td>
<td>Y</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr>
<td>Individual</td>
<td>Communicating an individual's care needs between local authority and care provider at the point of commissioning</td>
<td>3.86</td>
<td>Y</td>
<td>Y</td>
<td></td>
<td>Y</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr>
<td>Individual</td>
<td>Hospital admissions/discharge teams understand the care plan already in place and are able to provide the necessary care information to care providers on discharge</td>
<td>3.86</td>
<td>Y</td>
<td>Y</td>
<td>Y</td>
<td>Y</td>
<td>Y</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr>
<td>Individual</td>
<td>Consistency of care to an individual when a temporary worker needs to step in</td>
<td>3.79</td>
<td></td>
<td>Y</td>
<td>Y</td>
<td>Y</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr>
<td>Individual</td>
<td>Care Home sending information to GP system</td>
<td>3.21</td>
<td></td>
<td>Y</td>
<td></td>
<td>Y</td>
<td>Y</td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr>
<td>Service</td>
<td>Enabling easier implementation of new social care IT systems</td>
<td>4.00</td>
<td>Y</td>
<td></td>
<td></td>
<td>Y</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>Y</td>
</tr>
<tr>
<td>Service</td>
<td>Sharing elements of care planning information across many systems – componentisation of care plan</td>
<td>3.90</td>
<td>Y</td>
<td></td>
<td></td>
<td>Y</td>
<td>Y</td>
<td>Y</td>
<td></td>
<td></td>
<td></td>
</tr>
<tr>
<td>Service</td>
<td>As care providers move to digital systems (by 2024?), enable easier transfer of routine info to local authorities</td>
<td>3.79</td>
<td>Y</td>
<td></td>
<td></td>
<td>Y</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td>Y</td>
</tr>
<tr>
<td>Service</td>
<td>DHSC able to receive management information from all local authorities and care providers which uses agreed, understood and shared terminology</td>
<td>3.76</td>
<td>Y</td>
<td></td>
<td></td>
<td>Y</td>
<td></td>
<td></td>
<td></td>
<td>Y</td>
<td></td>
</tr>
<tr>
<td>Service</td>
<td>Population Health Management – greater ability to share health and care datasets to gain insights across a place</td>
<td>3.41</td>
<td>Y</td>
<td></td>
<td></td>
<td>Y</td>
<td>Y</td>
<td>Y</td>
<td></td>
<td>Y</td>
<td></td>
</tr>
<tr>
<td>Service</td>
<td>Care providers can interrogate the data they are capturing, rather than just recording it</td>
<td>3.41</td>
<td></td>
<td></td>
<td></td>
<td>Y</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr>
<td>Service</td>
<td>Local authorities receiving information from care providers that enables activity (review of needs etc) to be stratified through artificial intelligence</td>
<td>3.17</td>
<td>Y</td>
<td></td>
<td></td>
<td>Y</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
</tbody>
</table>

## Information Governance

Information Governance is a key aspect of the Authority's requirements for all assured solution systems suppliers under the DiSC Framework and contract agreements for the standards and capabilities who record considerable amounts of sensitive, personally identifiable information, this Standard intends to provide controls over the processing and use of that data. They must comply with these principles. For more information please visit [Information Governance (DSCR)](https://gpitbjss.atlassian.net/wiki/spaces/DSCR/pages/12238684246/Information+Governance+DSCR)
  
Care actors recording the MODS data in digital systems, must comply with the following principles specific to adult social care in the [Care Quality Commission Regulation: 17 Good governance](https://www.cqc.org.uk/guidance-providers/regulations-enforcement/regulation-17-good-governance) and the [Care Quality Commission Code of practice on confidential personal information](https://www.cqc.org.uk/sites/default/files/20180419%20Code%20of%20practice%20on%20CPI%20with%20GDPR%20and%20IRMER%20updates.pdf)

## Accessible Information Standard

From 1 August 2016 onwards, all organisations that provide NHS care and/or publicly-funded adult social care are legally required to follow the **Accessible Information Standard**:

“The Accessible Information Standard aims to make sure that people who have a disability, impairment or sensory loss get information that they can access and understand, and any communication support that they need from health and adult social care services.”

Adult social care providers and assured solution suppliers implementing the MODS should allow “patients, service users, carers and parents with a disability, impairment or sensory loss to:

Be able to contact, and be contacted by, services in accessible ways, for example via email or text message.
Receive information and correspondence in formats they can read and understand, for example in audio, braille, easy or large print.
Be supported by a communication professional at appointments if this is needed to support conversation, for example a British Sign Language interpreter.
Get support from health and care staff and organisations to communicate, for example to lip-read or use a hearing aid.”
[More information on the standard is available here](https://standards.nhs.uk/published-standards/accessible-information)

## Audit and provenance information

All information recorded must include audit information about when a record was created, modified, completed and authorised and by whom. This may also include proof of an attestation i.e. authorisation and the source system where the information was recorded.

Audit information is about the provenance of information record itself rather than information about who performed an activity.

[For more information about audit and provenance see the audit and provenance conceptual model.](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/implementation-guidance?page=26)

## Conceptual Model: Adult Social Care Record

**Version:** 0.2.1 Beta

**Release date:** 12.02.2024

**Abstract:** A visualisation of a conceptual data model for adult social care based on the International Standard EN ISO 13940:2016 and Contsys:2019

**Keywords:** Adult Social Care, Care Actor, Assessment, Care Plan, Instruction, Activity, Action, Administrative, Consent, Legal, Audit, Provenance, Conceptual Model, Adult Social Care Record, MODS, Minimum Operational Dataset, Data Standard

**Contact Point:** 
[Jira Service Management](https://metadata.atlassian.net/servicedesk/customer/portal/16)

Overview:
<p>///mermaid
graph TD
 accTitle: A visualisation of a conceptual data model for adult social care based on the International Standard EN ISO 13940:2016 and Contsys:2019
    accDescr: This diagram shows how different people and groups work together to support someone who needs care. At the heart of it all is the person being looked after, surrounded by the important details that keep them safe, such as their legal rights and their permission for care. A team of professionals—which could be an individual, a small team, or a large organization—uses this information to provide support and make decisions on the person's behalf. By carefully watching and recording what they see (observations), these helpers can figure out the best way to plan the person's care and daily activities. These observations act as a guide: they tell the team what is happening right now and help them decide which actions or plans are needed to help the person live their best life.

   subgraph AuditCol [" "]
        Audit[Audit <br> Info.]
    end

    subgraph Main Model [" "]
        
        subgraph TopActors [" "]
            Org[Organisation]
            Team[Team]
            Person[Person]
        end

        CareActors[Care Actors]
        Subject[Subject of Care]
        Obs[Observations]

        subgraph LeftInfo [" "]
            Legal[Legal Information]
            Admin[Administrative Information]
            Consent[Consent Information]
        end

        subgraph RightActions [" "]
            Assessments[Assessments]
            Plans[Care Plans]
            Actions[Instructions<br>Actions<br>Activities]
        end

        Org &amp; Team &amp; Person --&gt; CareActors
        
        CareActors --&gt; |"Supports<br>Provides Care for<br>Takes Decisions on Behalf of"| Subject
        Subject --&gt; |Refers to| Obs

        Legal &amp; Admin &amp; Consent --&gt; |Concerns| Subject

        Subject --&gt; |Performed for| Assessments &amp; Plans &amp; Actions

        Obs --&gt; |Recorded| Assessments &amp; Plans &amp; Actions
        Obs --&gt; |Influences| Assessments &amp; Plans &amp; Actions
    end

</p>

<ul class="details">
<li><a href="">Explain the visualisation of a conceptual data model for adult social care based on the International Standard EN ISO 13940:2016 and Contsys:2019</a>
<div>This diagram shows how different people and groups work together to support someone who needs care. At the heart of it all is the person being looked after, surrounded by the important details that keep them safe, such as their legal rights and their permission for care. A team of professionals—which could be an individual, a small team, or a large organization—uses this information to provide support and make decisions on the person's behalf. By carefully watching and recording what they see (observations), these helpers can figure out the best way to plan the person's care and daily activities. These observations act as a guide: they tell the team what is happening right now and help them decide which actions or plans are needed to help the person live their best life.</div>
</li>
</ul>


<p><a href="/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/implementation-guidance?page=19#">Care actors</a> include People, Teams and Organisations who can have multiple roles where they Support, Provide Care for and/or Take decisions on behalf of the Subject of Care</p>

<p><a href="/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/implementation-guidance?page=20#">Assessments</a> &amp; <a href="/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/implementation-guidance?page=21#">Care plans</a> are performed for the Subject of Care and can be influenced by <a href="/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/implementation-guidance?page=23#">Observations</a> about the Subject of Care. These result in <a href="/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/implementation-guidance?page=22#">Instruction, activity &amp; actions</a> which may result in further <a href="/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/implementation-guidance?page=23#">Observations</a> being recorded which in turn may trigger Re<a href="/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/implementation-guidance?page=20#">Assessments</a> &amp; <a href="/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/implementation-guidance?page=21#">Care plan</a> reviews.</p>

<p><a href="/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/implementation-guidance?page=25#">Consent and legal information</a> concerning the subject of care must be captured to inform the provision of care, as well as <a href="/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/implementation-guidance?page=24#">Administrative Information</a> that will inform operational delivery of care.</p>

<p>All adult social care records must include <a href="/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/implementation-guidance?page=26#">Audit Information</a>.</p>

### Care actor

Organisation, team or person participating in health and adult social care.

<p>///mermaid
 graph TD
 accTitle: Visualisation of a conceptual data model for Care Actor - Organisation, team or person participating in health and adult social care.
    accDescr: When someone needs support with their health or daily life, they are the "Subject of Care" at the heart of a big team. This team includes family and friends (like personal contacts or unpaid carers) and professional care workers who all work together to provide the right help. To make sure everything runs smoothly, organizations like the NHS or local councils (the commissioners and service providers) organize and fund the care, while voluntary groups offer extra support to the person and their family. Most importantly, the person receiving care is involved in every step, but if they ever need help making a choice, a trusted "proxy" can step in to make decisions on their behalf to ensure they always get the best possible support.
subgraph Taxonomy ["Left Diagram: Taxonomy &amp; Inheritance Structure"]
        direction TB

         CareTeam_T[Care Team] --&gt;|part of| Person_T[Person]

        
        Organisation_T[Organisation] --&gt;|is a| CareActor_T[Care Actor]
        Person_T --&gt;|is a| CareActor_T
        CareActor_T --&gt;|has role 1..*| Role_T[Role]

      
        subgraph Providers [" "]
            direction LR
            LocalAuthority_T[Local Authority] --&gt; Commissioner_T[Commissioner]
            HealthcareProvider_T[Healthcare Provider] --&gt; ServiceProvider_T[Service Provider]
            SocialCareProvider_T[Social Care Provider] --&gt; ServiceProvider_T
            VoluntaryOrganisation_T[Voluntary Organisation] --&gt; ServiceProvider_T
        end

        subgraph GeneralRoles [" "]
            direction LR
            UnpaidCarer_T[Unpaid Carer]
            PersonalContact_T[Personal Contact]
            SubjectOfCare_T[Subject of Care]
            Proxy_T[Proxy for Subject of Care]
        end

        subgraph CareWorkers [" "]
            direction LR
            LocalAuthorityProfessional_T[Local Authority Professional] --&gt; CareWorker_T[Care Worker]
            Volunteer_T[Volunteer] --&gt; CareWorker_T
            CareProfessional_T[Care Professional] --&gt; CareWorker_T
            HealthProfessional_T[Health Professional] --&gt; CareWorker_T
        end


        Commissioner_T --&gt;|is a| Role_T
        ServiceProvider_T --&gt;|is a| Role_T
        UnpaidCarer_T --&gt;|is a| Role_T
        PersonalContact_T --&gt;|is a| Role_T
        SubjectOfCare_T --&gt;|is a| Role_T
        Proxy_T --&gt;|is a| Role_T
        CareWorker_T --&gt;|is a| Role_T
    end

    subgraph ER_Model ["Right Diagram: Functional Relationship Model"]
        direction TB

       
        ServiceProvider_R[Service Provider] --- Commissioner_R[Commissioner]
        
        
        CareTeam_R[Care Team]
        
       
        CareWorker_R[Care Worker] --- SubjectOfCare_R[Subject of Care] --- UnpaidCarer_R[Unpaid Carer]
        
       
        VoluntaryOrganisation_R[Voluntary Organisation]
        Proxy_R[Proxy for Subject of Care]
        PersonalContact_R[Personal Contact]

       
        ServiceProvider_R --&gt;|0..1| Commissioner_R
        ServiceProvider_R --&gt;|0..* supports| SubjectOfCare_R
        Commissioner_R --&gt;|0..1 supports| SubjectOfCare_R
        
        CareWorker_R --&gt;|1..* part of| CareTeam_R
        CareTeam_R --&gt;|0..* provides care for 1..*| SubjectOfCare_R
        UnpaidCarer_R --&gt;|1..* part of| CareTeam_R
        
        CareWorker_R --&gt;|* employed by 0..1| ServiceProvider_R
        CareWorker_R --&gt;|0..* provides care for 1..*| SubjectOfCare_R
        UnpaidCarer_R --&gt;|0..* provides care for 1..*| SubjectOfCare_R
        
        CareWorker_R --&gt;|* employed by 0..1| VoluntaryOrganisation_R
        VoluntaryOrganisation_R --&gt;|0..* supports| SubjectOfCare_R
        VoluntaryOrganisation_R --&gt;|0..* supports| UnpaidCarer_R
        
        Proxy_R --&gt;|0..* takes decisions on behalf of 1| SubjectOfCare_R
        SubjectOfCare_R --&gt;|1 has 0..*| PersonalContact_R
        
        SubjectOfCare_R --&gt;|1..* ordinarily resident in 0..1| Commissioner_R
        SubjectOfCare_R --&gt;|1..* ordinarily resident in 0..1| ServiceProvider_R
    end
</p>

<ul class="details">
<li><a href="">Explain the visualisation of a conceptual data model for Care Actor</a>
<div>When someone needs support with their health or daily life, they are the "Subject of Care" at the heart of a big team. This team includes family and friends (like personal contacts or unpaid carers) and professional care workers who all work together to provide the right help. To make sure everything runs smoothly, organizations like the NHS or local councils (the commissioners and service providers) organize and fund the care, while voluntary groups offer extra support to the person and their family. Most importantly, the person receiving care is involved in every step, but if they ever need help making a choice, a trusted "proxy" can step in to make decisions on their behalf to ensure they always get the best possible support.</div>
</li>
</ul>

<p>
A [Person](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464193), [Organisation](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464197) or **Care Team** can be a [Care Actor](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464067). Each [Care Actor](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464067) will have a **Role** in a particular context. For example the same [Person](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464193) may have one or more roles in various different contexts:

[Subject of care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685)
[Unpaid carer](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463690)
[Personal contact](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463950)
[Care worker](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463617)
[Proxy for subject of care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463949)
**Service Providers** are all [Organisations](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464197) that provide a [type of service](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=463710) and include:

[Social Care Providers](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=464567)
**Healthcare providers including** [General practices](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=464566)
**Voluntary Organisations**
and in some cases **Local Authorities**.
Service Providers are [Organisations](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464197) that *support* the **[Subject of care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685)** and employ **[Care workers](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463617)** who *[provide care for](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=465636)* the **[Subject of care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685)**, sometimes as *part of* a **[Care Team](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?;elementId=463701)**.

Unpaid carers *[provide care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=465819)* for the **[Subject of care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685)** and can be *part of* the **[Care Team](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?p;elementId=463701)**.

**[Personal contacts](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463950)** and their *relationship* with the **[Subject of care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685)** is captured as part the record.

If the **[Subject of care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685)** does not have capacity, a **[Proxy for subject of care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463949)** may be appointed to take *decisions* on their behalf and the *relationship* between them and the **[Subject of care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685)**, alongside **[Legal information](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463609)** is recorded.

**[Care Actors](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464067)** can also be a *Commissioner* of services i.e the [source of care funding](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=465036). This may be determined by the **Local Authority** that the **[Subject of care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685)** and/or **[Unpaid carer](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463690)** is *[ordinarily resident in](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=463700)*.
</p>

### Assessment

The process of evaluating a person’s needs, wishes, strengths and preferences, as well as identifying any relevant risks associated with them.

<p>///mermaid
graph TD
accTitle: Visualisation of a conceptual data model for Assessment - the process of evaluating a person’s needs, wishes, strengths and preferences, as well as identifying any relevant risks associated with them.
    accDescr: When a person needs support, their care team carries out a formal check, called an assessment, to understand their unique situation and how best to help them. This process involves looking at the person’s strengths, what they are good at, and what they want for their own life, while also identifying any risks or specific needs they have. Professional care workers lead these checks, but they always listen to the person or a trusted friend acting on their behalf to make sure the final plan reflects their true wishes and preferences. Because lives change, these assessments are regularly reviewed and updated to ensure the support stays right for the person, making sure they stay safe, healthy, and in control of their future.
subgraph ContextLayer [" "]
        direction LR
        Observation[Observation]
        Review[Review]
    end

    subgraph PrimaryActors [" "]
        direction LR
        CareActor[Care Actor]
        Proxy[Subject of Care Proxy]
        SubjectOfCare[Subject of Care]
    end

    subgraph CoreHub [" "]
        Assessment[Assessment]
    end

    Observation --&gt;|1 influences| Assessment
    Review --&gt;|0..* reviews 1| Assessment

    CareActor --&gt;|1..* performs| Assessment
    CareActor --&gt;|1..* completes| Assessment
    CareActor --&gt;|1 authorises| Assessment
    
    Proxy --&gt;|1 expressed by 1| Assessment
    SubjectOfCare --&gt;|1 performed for 0..*| Assessment

    subgraph Subtypes [" "]
        direction LR
        NeedsAssessment[Needs Assessment]
        MentalCapacityAssessment[Mental Capacity Assessment]
        FinancialAssessment[Financial Assessment]
        RiskAssessment[Risk Assessment]
    end

    Assessment --&gt;|is a| NeedsAssessment
    Assessment --&gt;|is a| MentalCapacityAssessment
    Assessment --&gt;|is a| FinancialAssessment
    Assessment --&gt;|is a| RiskAssessment

    MentalCapacityAssessment --- DoLS[DoLS]

    FinancialCircumstance[Financial circumstance]
    FinancialAssessment --&gt;|1| FinancialCircumstance
    SubjectOfCare --&gt;|1 ... 0..*| FinancialCircumstance

    subgraph RiskDetails [" "]
        direction LR
        SafeguardingConcern[Safeguarding Concern]
        Risk[Risk]
    end
    RiskAssessment --&gt;|1 identifies 0..*| SafeguardingConcern
    RiskAssessment --&gt;|1 identifies 0..*| Risk
    SubjectOfCare --&gt;|1 has 0..*| SafeguardingConcern
    SubjectOfCare --&gt;|1 has 0..*| Risk

    subgraph NeedsDetails [" "]
        direction LR
        Need[Need]
        Wishes[Wishes]
        Strength[Strength]
        Preferences[Preferences]
    end
    NeedsAssessment --&gt;|1 evaluates 0..*| Need
    NeedsAssessment --&gt;|1 evaluates 0..*| Wishes
    NeedsAssessment --&gt;|1 evaluates| Strength
    NeedsAssessment --&gt;|1 evaluates 0..*| Preferences
    
    SubjectOfCare --&gt;|1 has| Need
    SubjectOfCare --&gt;|1 expresses 0..*| Wishes

</p>
<ul class="details">
<li><a href="">Explain the visualisation of a conceptual data model for Assessment</a>
<div>When a person needs support, their care team carries out a formal check, called an assessment, to understand their unique situation and how best to help them. This process involves looking at the person’s strengths, what they are good at, and what they want for their own life, while also identifying any risks or specific needs they have. Professional care workers lead these checks, but they always listen to the person or a trusted friend acting on their behalf to make sure the final plan reflects their true wishes and preferences. Because lives change, these assessments are regularly reviewed and updated to ensure the support stays right for the person, making sure they stay safe, healthy, and in control of their future.</div>
</li>
</ul>

<p>
**[Assessments](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=584289)** are performed for the **[Subject of care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685)** and can be *expressed by* a **[Proxy for subject of care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463949)** if the **[Subject of care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685)** does not have **[Mental Capacity](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=463716)**.

**[Care Actors](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464067)** *perform, complete and authorise* **[Assessments](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463712)** of the:

**[Needs](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=465037&amp;classId="")**
**[Risks](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463973)**
**[Safeguarding concerns](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463976)**
**[Strengths](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464142)**
**[Wishes](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464122)**
**[Preferences](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464123)**
and **[Mental Capacity](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=463716)**
of the **[Subject of care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685)**.

**[Needs](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=465037&amp;classId="")**, **[Risks](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463973)**, **[Safeguarding concerns](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463976)**, **[Strengths](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464142)**, **[Wishes](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464122)** and **[Preferences](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464123)** are recorded as **[Observations](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463622)** in reference to the **[Subject of care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685)** during an **[Assessment](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463712)**. **[Observations](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463622)** are recorded before, during (and after) **[Assessments](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463712)**. **[Observations](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463622)** about the **[Subject of care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685)** made before the **[Assessment ](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463712)**should be available during the **[Assessment](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463712)** as they can influence both assessment and care planning processes.

The Adult Social Care Record (MODS) defines three typical types of assessments:

**[Care Needs Assessments](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=463713)**
**[Risk Assessments](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=613779)**
**[Mental Capacity Assessments](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463712)**
**[Care Needs Assessments ](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=463713)** *evaluate* the **[Needs](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=465037)**, **[Strengths](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464142)**, **[Wishes](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464122)**, **[Preferences](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464123)** of the **[Subject of care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685)**. **[Needs](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=465037&amp;classId="")** include information about the **[significance](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=463708)** and **[urgency](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=465823)** of the care need and can include a reference to a list of healthcare **[problems](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464010)**. **[Strengths](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464142)**, **[Wishes](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464122)**, **[Preferences](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464123)** are *evaluated* and recorded as a narrative description.

**[Risk Assessments](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=613779)** *identify* **[Risks](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463973)** and **[ Safeguarding concerns](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463976)**, as well as recording the **[reason for the risk assessment](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=464158)**, any **[Care Actors](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464067)** that the **[Risk](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463973)** *[involves](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=464157)* and whether the **[Subject of care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685)** has an **[understanding](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=463977)** of the risks. **[Risks](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463973)** can include information about **[trigger factors](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=98678)**, **[relapse indicators](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=98705)** and information about the **[Care Actors](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464067)** who should be *[informed](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=465829)*.

**[Mental Capacity Assessments](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463959)**, includes a narrative of whether an assessment of the mental capacity of the **[Subject of care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685)** has been undertaken. The narrative statement includes what capacity the decision relates to, the outcome of the assessment and the best interest decisions if person lacks capacity. **[Mental Capacity Assessment](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463712)** records should include a reference to the location of the **[Document](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464127)** where the mental capacity assessment is recorded.

**[Assessment](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463712)** records should include details about the scheduled **[Reviews](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=46412)**.

*Note: Financial Assessments are currently out-of-scope for the current iteration of the Adult Social Care Record.*
</p>

### Care plan

A written plan typically recorded after an assessment, addressing the needs and risks associated with the person receiving care and setting out goals and instructions for the care they will receive. The person receiving care should have the opportunity to be fully involved in the plan and to say what their priorities are. If the person receiving care is in a care home, home care (domiciliary care), or attends a day service, the plan for their daily care may also be called a care plan.

<p>///mermaid
graph TD
accTitle: Visualisation of a conceptual data model for Care plan - a written plan typically recorded after an assessment, addressing the needs and risks associated with the person receiving care and setting out goals and instructions for the care they will receive.
    accDescr: A care plan is like a helpful roadmap designed specifically for you to ensure you get the right support. It is built by listening to your personal wishes and preferences, looking at what you are already good at, and identifying the areas where you might need a hand to stay safe. For any of these plans to start, you—or someone you trust to speak for you—must understand the plan and agree to it, which is known as giving consent. Professional care workers then use this agreement to set clear goals and write down simple instructions for the team to follow. This process makes sure that every action taken is centered on what matters most to you, helping you stay in control of your life while receiving the help you need.
   subgraph UpperContext [" "]
        direction LR
        Consent[Consent]
        CareActor[Care Actor]
    end

    subgraph CoreActors [" "]
        direction LR
        Proxy[Subject of Care Proxy]
        SubjectOfCare[Subject of Care]
    end

    subgraph Hub [" "]
        CarePlan[Care Plan]
    end

    subgraph ExternalInfluences [" "]
        direction LR
        Observation[Observation]
        Wishes[Wishes]
        Preferences[Preferences]
    end

    subgraph PlanComponents [" "]
        direction LR
        Need[Need]
        Risk[Risk]
        Strength[Strength]
        Goal[Goal]
        Instruction[Instruction]
    end

    CareActor --&gt;|1..* performs| CarePlan
    CareActor --&gt;|1..* completes| CarePlan
    CareActor --&gt;|1 authorises| CarePlan

    Proxy --&gt;|1 expressed by| CarePlan
    SubjectOfCare --&gt;|1 performed for 0..*| CarePlan

    CarePlan --&gt;|1 requires 1| Consent
    SubjectOfCare --&gt;|1 gives 1| Consent
    Proxy --&gt;|1 states 1| Consent

    Observation --&gt;|0..* influences 1| CarePlan
    Wishes --&gt;|0..* influences 1| CarePlan
    Preferences --&gt;|0..* influences 1| CarePlan

    CarePlan --&gt;|1 addresses 0..*| Need
    CarePlan --&gt;|1 addresses 0..*| Risk
    CarePlan --&gt;|1 evaluates 0..*| Strength
    CarePlan --&gt;|1 targets 1..*| Goal
    CarePlan --&gt;|1 determines 0..*| Instruction

    Instruction --&gt;|0..* targets 0..*| Goal
    Instruction --&gt;|0..* is performed for 1| SubjectOfCare
    SubjectOfCare --&gt;|1 has 0..*| Need
    SubjectOfCare --&gt;|1 has 0..*| Risk
</p>
<ul class="details">
<li><a href="">Explain the visualisation of a conceptual data model for Care plan - a written plan typically recorded after an assessment, addressing the needs and risks associated with the person receiving care and setting out goals and instructions for the care they will receive.</a>
<div>A care plan is like a helpful roadmap designed specifically for you to ensure you get the right support. It is built by listening to your personal wishes and preferences, looking at what you are already good at, and identifying the areas where you might need a hand to stay safe. For any of these plans to start, you—or someone you trust to speak for you—must understand the plan and agree to it, which is known as giving consent. Professional care workers then use this agreement to set clear goals and write down simple instructions for the team to follow. This process makes sure that every action taken is centered on what matters most to you, helping you stay in control of your life while receiving the help you need.</div>
</li>
</ul>

<p>
**[Care Actors](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464067)** *perform, complete and authorise* **[Care plans](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463951)** that *address* the:

**[Needs](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=465037&amp;classId="")**
**[Risks](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463973)**
**[Safeguarding concerns](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463976)**
that the **[Subject of care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685)** has.

**[Care plans](hhttps://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463951)** *target* **[Goals](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=465039)** for the **[Subject of care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685)** within the context of **[Observations](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463622)** about the **[Subject of care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685)**, in particular, their:

**[Strengths](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464142)**
**[Wishes](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464122)**
**[Preferences](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464123)**
and **[[Mental Capacity](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=463716)**
**[Care plans](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463951)** *determine* the set of **[Instructions](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=464178)** for the provision of care based on these **[Goals](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=465039)**.

**[Observations](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463622)** such as **[Needs](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=465037&amp;classId="")**, **[Risks](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463973)**, **[Safeguarding concerns](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463976)**, **[Strengths](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464142)**, **[Wishes](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464122)** and **[Preferences](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464123)** can be recorded before, during (and after) care planning and/or assessment. **[Observations](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463622)** about the **[Subject of care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685)** should be available during the care planning process.

To receive planned care and support the **[Subject of care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685)** is required to *give* **[Informed Consent](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463956)** or if the **[Subject of care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685)** does not have **[Mental Capacity](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=463716)** the **[Proxy for subject of care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463949)** is required to *express* **[Informed Consent](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463956)** for the **[Care plan](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463951)**.
</p>

### Instruction, activity action

Records of instructions, activities and actions detail how care should be, and how care has been, provided. Instructions target goals from the care plan and determine a set of planned Activities. Actions log that a planned (or unplanned) activity has been completed and any associated outcomes or observations.

<p>///mermaid
graph TD
accTitle: Visualisation of a conceptual data model for Instruction, activity action
    accDescr: When you have a health goal, your care team writes down clear instructions on exactly what needs to happen to help you reach it. These instructions are turned into specific activities, like a nurse giving a vaccination, a doctor performing a check-up, or a care worker helping with daily tasks. Every time one of these tasks is finished, it is recorded as an "action" so there is a clear history of what was done, who did it, and when it happened. This careful tracking makes sure everyone on your team knows exactly how you are being supported and ensures that every step taken is helping you stay healthy and safe
    %% Top Level Activity Grid
    subgraph Activities ["Types of Activity"]
        direction LR
        Vaccination ~~~ Device ~~~ ToC[Transfer of Care] ~~~ Comm[Communication]
        Medication ~~~ Procedure ~~~ Task ~~~ Referral ~~~ Service
    end

    %% Main Logic Flow with Cardinality
    Goal -- "0..* targets 0..1" --&gt; Instruction
    Instruction -- "1 determines 0..*" --&gt; Activity
    Activity -- "0..* performed in 0..1" --&gt; Location
    
    %% Connecting Subtypes to Parent
    Activity --- Activities

    %% Operational Links
    Activity -- "0..* performed for 1" --&gt; SubjectOfCare
    Activity -- "0..* responsible for 0..*" --&gt; CareActor
    
    Action -- "0..* recorded 0..*" --&gt; Activity
    Action -- "0..* performed by 1..*" --&gt; CareActor
    Action -- "0..* during 0..1" --&gt; Visit
    Action -- "1..* recorded 0..1" --&gt; Observation
    Action -- "0..* performed for 1" --&gt; SubjectOfCare

    Location -- "1 contains 0..*" --&gt; Visit

</p>

<ul class="details">
<li><a href="">Explain the visualisation of a conceptual data model for Instruction, activity &amp; action</a>
<div>When you have a health goal, your care team writes down clear instructions on exactly what needs to happen to help you reach it. These instructions are turned into specific activities, like a nurse giving a vaccination, a doctor performing a check-up, or a care worker helping with daily tasks. Every time one of these tasks is finished, it is recorded as an "action" so there is a clear history of what was done, who did it, and when it happened. This careful tracking makes sure everyone on your team knows exactly how you are being supported and ensures that every step taken is helping you stay healthy and safe.</div>
</li>
</ul>
<p>
**[Instructions](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=464178)** are typically determined in the **[Care plan](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463951)** and determine a set of **[Activities](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464012)** that *target* **[Goals](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=465039)** for the **[Subject of care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685)** from the **[Care plan](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463951)**.

**[Activities](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464012)** are *performed* for the **[Subject of care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685)** and are typically (not always) scheduled or planned in advance. **[Activities](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464012)** include:

**[Vaccinations](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464053)**
provision of **[Medications](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464052)**
Healthcare **[Procedures](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464054)**
**[Transfers of Care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464128)**
**[Communication](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464009)** activities
**[Tasks](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464055)** provision of **[Devices](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464570)**
**[Referrals](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464056)**
or **[Services](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464057)**
**[Activities](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464012)** will usually be (not always) *performed* in a given **[Location](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464194)**.

**[Actions](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464013)** “log” that a planned **[Activity](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464012)** has been *performed* including when and where it was *performed*, and *by whom*, as well as **[Observations](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463622)** that were made whilst the **[Activity](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464012)** was taking place.

Note: The model is based on the [EHR Information Model](https://specifications.openehr.org/releases/RM/latest/ehr.html#_model_overview):
</p>
<p>///mermaid
graph LR
    Instruction --- Activity1[ACTIVITY]
    Instruction --- Activity2[ACTIVITY]
    Instruction --- Activity3[ACTIVITY]

    Activity1 --- Action1_1["ACTION 2aug2008 12:00"]
    Activity1 --- Action1_2["ACTION 6aug2008 15:45"]

    Activity2 --- Action2_1["ACTION 4aug2008 10:30"]

    Activity3 --- Action3_1["ACTION 1aug2008 10:30"]
    Activity3 --- Action3_2["ACTION 3sep2008 10:40"]
    Activity3 --- Action3_3["ACTION 1oct2008 10:30"]

    StandaloneAction["ACTION 13sep2008 11:23"]
</p>

### Observation

A record of something a care actor has seen, heard, or noticed in reference to the health or social wellbeing of the Subject of care. These can include objective and subjective observations and can be recorded by healthcare professionals and/or other care actors.

<p>///mermaid
graph TD
accTitle: Visualisation of a conceptual data model for Observation
    accDescr: An "observation" is simply a way for your care team to write down important information about your health and daily life, covering everything from your personal wishes and strengths to medical facts like allergies or test results. When a professional notices something or you share how you are feeling, they record it to create a clear picture of your situation, noting where it happened and who was involved. These gathered details are vital because they help your team make the right decisions about your future support. By looking at these observations, your team can update your care plan, check your progress in reviews, and give specific instructions to make sure the help you receive always matches what matters most to you.
    %% Top Level Observation Types (Inheritance)
    subgraph ObservationTypes [Types of Observation]
        direction LR
        Problem ~~~ Allergies ~~~ Alert ~~~ InvRes[Investigation Result] ~~~ Outcome
        Incident ~~~ SafCon[Safeguarding Concern] ~~~ Need ~~~ Strength ~~~ Risk
        Circumstance ~~~ DailyLiving[Daily Living] ~~~ Preferences ~~~ Wishes ~~~ Environment
    end

    %% Core Entity
    Observation((Observation))

    %% Central Relationships with Cardinality
    Observation -- "is a" --&gt; ObservationTypes
    
    SubjectOfCare -- "1 refers to 0..*" --&gt; Observation
    CareActor -- "1 records 0..*" --&gt; Observation
    Observation -- "0..* involves 0..*" --&gt; CareActor
    Observation -- "1..* performed in 1" --&gt; Location

    %% Downstream Influences
    Observation -- "influences 0..*" --&gt; Review
    Observation -- "influences 0..*" --&gt; CarePlan[Care Plan]
    Observation -- "influences 0..*" --&gt; Assessment
    Observation -- "influences 0..*" --&gt; Instruction

</p>

<ul class="details">
<li><a href="">Explain the visualisation of a conceptual data model for Observation</a>
<div>An "observation" is simply a way for your care team to write down important information about your health and daily life, covering everything from your personal wishes and strengths to medical facts like allergies or test results. When a professional notices something or you share how you are feeling, they record it to create a clear picture of your situation, noting where it happened and who was involved. These gathered details are vital because they help your team make the right decisions about your future support. By looking at these observations, your team can update your care plan, check your progress in reviews, and give specific instructions to make sure the help you receive always matches what matters most to you.</div>
</li>
</ul>
<p>
**[Observations](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463622)** are *recorded* by a **[Care Actor](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=58691)** and refer to the **[Subject of care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685)**.

An **[Observation](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463622)** is *performed* in a **[Location](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464194)** and multiple **[Care Actors](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464067)** could be *involved*. **[Observations](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463622)** *influence* **[Assessments](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463712)**, **[Care plans](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463951)** and **[Instructions](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=464178)**, as well as being a *trigger* for **[Reviews](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=46412)**.

**[Observations](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463622)** recorded as part of social care provision including:

**[Needs](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=465037&amp;classId="")**
**[Risks](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463973)**
**[Safeguarding concerns](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463976)**
**[Strengths](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464142)**
**[Wishes](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464122)**
**[Preferences](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464123)**
**[Daily Living](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=466369)**
**[Alert](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464180)**
**[Incident](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463988)**
**[Circumstance](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463989) (including [Environment](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464124))**
**[Outcome](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=465118)**
Some **[Observations](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463622)** would typically be recorded as part of healthcare provision such as:

* **[Allergies](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464181)**
* **[Investigation Results](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464182)**
* **[Problem](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464010)** list
and should be shared with adult social care providers and included in an Adult Social Care record.
</p><p></p>

### Administrative Information

Information recorded when a person interacts with health and adult social care actors and concerning the management of a person's care and those responsible for caring for them.

<p>///mermaid
graph TD
accTitle: Visualisation of a conceptual data model for Administrative Information
    accDescr: To help your care run smoothly, there is a lot of behind-the-scenes work focused on keeping everyone connected through clear communication and organized records. This includes sharing documents and important details about when you start or finish using a care service. Your care worker will regularly schedule a "review" to check in on how things are going. This review is the main place where big decisions happen; your team looks at your assessments, daily activities, and specific instructions to decide if your overall care plan needs to be updated. This process ensures that the support you receive is always current and based on what is actually happening in your life.
    %% Main People and Entities
    Sub[Subject of Care]
    CA[Care Actor]
    SP[Service Provider]

    %% Central Administrative Items
    Comm[Communication]
    Doc[Document]
    Adm[Admission details]
    Dis[Discharge Details]
    Occ[Occupancy]
    Rev[Review]

    %% Supporting Concepts (Side boxes)
    subgraph Context
        Location
        Address
        Event
    end

    %% Administrative Flow
    Comm -- sends/receives --&gt; CA
    Comm -- concerns --&gt; Sub
    
    Doc -- records/concerns --&gt; CA
    Doc -- concerns --&gt; Sub
    
    Adm -- provides/concerns --&gt; SP
    Adm -- concerns --&gt; Sub
    
    Dis -- provides/concerns --&gt; SP
    Dis -- concerns --&gt; Sub
    
    Occ -- concerns --&gt; SP

    CA -- Schedules --&gt; Rev

    %% Review Fan-out
    Rev -- concerns --&gt; Assessment
    Rev -- concerns --&gt; Instruction
    Rev -- concerns --&gt; Action
    Rev -- concerns --&gt; Activity
    Rev -- concerns --&gt; CarePlan

</p>

<ul class="details">
<li><a href="">Explain the visualisation of a conceptual data model for Administrative information</a>
<div>To help your care run smoothly, there is a lot of behind-the-scenes work focused on keeping everyone connected through clear communication and organized records. This includes sharing documents and important details about when you start or finish using a care service. Your care worker will regularly schedule a "review" to check in on how things are going. This review is the main place where big decisions happen; your team looks at your assessments, daily activities, and specific instructions to decide if your overall care plan needs to be updated. This process ensures that the support you receive is always current and based on what is actually happening in your life.</div>
</li>
</ul>
<p>
**[Administrative](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464126)** information includes records of:

**[Communications](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464009)**
**[Documents](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464127)**
**[Admission details](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464147)**
**[Discharge details](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=465031)**
and **[Reviews](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=46412)**
*concerned with the managemen*t and *provision* of care for the **[Subject of care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685)**.

**[Administrative](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464126)** information also includes records of:

**[Occupancy](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=465254)**
*concerning* **[Service providers](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=465828)**.

**[Administrative](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464126)** information also includes a number of standards for recording:

**[Events](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464206)**
**[Locations](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464194)**
**[Addresses](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464208)**
these typically would not form distinct records themselves but are building blocks used as part of other records.
</p>

### Consent and legal information

Records of informed consent and legal information for a person’s care.

<p>///mermaid
graph TD
    accTitle: visualisation of a conceptual data model for Consent and legal information
    accDescr: Everything in your care starts with your permission, which is often called giving informed consent. You are at the heart of every decision, but you can also have a trusted person—like a legal proxy or someone with power of attorney—help make choices for you if you are ever unable to do so yourself. There are also special documents used to record your specific wishes ahead of time, such as how you want to be treated in an emergency or if you want to refuse certain medical treatments. The most important rule shown here is that your clear agreement is required before your care team can start a new care plan, carry out health tests, or follow specific instructions. This process ensures you stay in control of your health and that your personal choices are always respected.

    %% Top Level Legal/Professional Entities
    CA[Care Actor]
    Sub[Subject of Care]
    Proxy[Subject of Care Proxy]
    LPA[Lasting Power of Attorney]
    IC[Informed Consent]

    %% Legal Documents (Left and Right)
    DoLS[DoLS]
    ADRT[Advanced Decision to Refuse Treatment]
    CPR[CPR Decision]
    AS[Advanced Statement]
    MHA[Mental Health Act or Equivalent]

    %% Organizational Logic
    CA -- "1 assigns 0..*" --&gt; LPA
    LPA -- "0..* is assigned to 1" --&gt; Sub
    LPA --- Proxy
    
    Sub -- "1 has 0..*" --&gt; DoLS
    Sub -- "1 concerns 0..*" --&gt; ADRT
    Sub -- "1 concerns 0..*" --&gt; CPR
    Sub -- "1 concerns 0..*" --&gt; AS
    Sub -- "1 concerns 0..*" --&gt; MHA
    
    Sub -- "1 states 0..*" --&gt; IC
    Proxy -- "1 states 0..*" --&gt; IC

    %% Consented Processes
    subgraph Processes [Processes Requiring Consent]
        direction LR
        Ass[Assessment] ~~~ Inst[Instruction] ~~~ Actn[Action] ~~~ Actv[Activity] ~~~ CP[Care Plan]
    end

    IC -- "0..1 requires 0..*" --&gt; Ass
    IC -- "0..1 requires 0..*" --&gt; Inst
    IC -- "0..1 requires 0..*" --&gt; Actn
    IC -- "0..1 requires 0..*" --&gt; Actv
    IC -- "0..1 requires 0..*" --&gt; CP
</p>
<ul class="details">
<li><a href="">Explain the visualisation of a conceptual data model for Consent and legal information</a>
<div>Everything in your care starts with your permission, which is often called giving "informed consent". You are at the heart of every decision, but you can also have a trusted person—like a legal proxy or someone with power of attorney—help make choices for you if you are ever unable to do so yourself. There are also special documents used to record your specific wishes ahead of time, such as how you want to be treated in an emergency or if you want to refuse certain medical treatments. The most important rule shown here is that your clear agreement is required before your care team can start a new care plan, carry out health tests, or follow specific instructions. This process ensures you stay in control of your health and that your personal choices are always respected.</div>
</li>
</ul>
<p>
Records of legal information include:

**[Advance decision to refuse treatment (ADRT)](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464014)**
**[Advance statement](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=465045)**
**[Cardio-pulmonary resuscitation](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463955)**
**[Deprivation of Liberty Safeguards (DoLS) or equivalent](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463958)**
**[Lasting power of attorney](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463957)**
**[Mental Health Act or Equivalent](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463960)**
**[Lasting power of attorney](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463957)** is assigned by a **[Care Actor](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464067)** to an [attorney](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=465103) who can act as a **[Proxy for subject of care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463949)**.

A record of **[Informed consent](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463956)** is *required* for:

**[Assessments](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463712)**
**[Care plans](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463951)**
**[Instructions](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=464178)**
**[Activities](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=584589)**
and **[Actions](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464013)**
**[Informed](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=465645)** consent can be *given or refused* by the Subject of care, or if the **[Subject of care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685)** does not have **[Mental Capacity](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=463716)** the **[Proxy for subject of care](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463949)** is required to *give or refuse* **[Informed Consent](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463956)**.
</p><p></p>

### Audit Information

Information about the provenance of all information recorded and any changes to an information record for audit purposes:

<p>///mermaid
graph TD
accTitle: Visualisation of a conceptual data model for Audit Information
    accDescr: To make sure your information is always handled safely, every time a professional—like a doctor or social worker—looks at or updates your records, a digital "diary" called a change log automatically takes a note of it. Whether they are writing a new document, changing an old one, or even deleting something, the system keeps track of exactly what happened, who did it, and when. This creates a permanent history of your information that acts as proof to show that everything is being done correctly and fairly. By having this clear record of every change made by a care worker, your team can always look back at previous versions of your files to see how your support has evolved, ensuring your details are accurate and your privacy is protected.
    %% Main Entities
    Doc[Document]
    Sys[System]
    CL[Change Log]
    VR[Versioned Record]
    CA[Care Actor]

    %% Relationships with Cardinality
    Doc -- "0..1 proves 1" --&gt; CL
    Sys -- "1 recorded in 1" --&gt; CL
    CL -- "1 relates to 1" --- VR
    CA -- "1 Creates, Modifies, Amends, Attests, Deletes 1" --&gt; CL
</p>

<ul class="details">
<li><a href="">Explain the visualisation of a conceptual data model for Audit Information</a>
<div>To make sure your information is always handled safely, every time a professional—like a doctor or social worker—looks at or updates your records, a digital "diary" called a change log automatically takes a note of it. Whether they are writing a new document, changing an old one, or even deleting something, the system keeps track of exactly what happened, who did it, and when. This creates a permanent history of your information that acts as proof to show that everything is being done correctly and fairly. By having this clear record of every change made by a care worker, your team can always look back at previous versions of your files to see how your support has evolved, ensuring your details are accurate and your privacy is protected.</div>
</li>
</ul>
<p>
All information records in an Adult Social Care Record (MODS) must be **[Versioned Records](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=465097)**.

All **[Versioned Records](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=465097)** must include a **[Change Log](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463963)** that captures information about when a record was created, modified, completed and attested (authorised) and by whom. If a **[Versioned Record](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=465097)** has been attested a **[Document](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464127)** can be associated with the **[Change Log](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463963)** that proves the attestation e.g. a signature. In addition the change log should capture a **[system identifier](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=463968)** for the System where the change was recorded in.

If the **[Versioned Record](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=465097)** is immutable, then the specific information about the **[Change](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=465122)** (in the **[Change Log](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463963)**) could be inferred by examining each version of the record, otherwise the information about the specific **[Change](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?elementId=465122)** (in the **[Change Log](https://standards.nhs.uk/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463963)**) must be detailed enough to recreate the record at a specific point in time.
</p>

## Glossary

[A draft glossary and comparison of terms used across adult social care MODS data standards is available here:](https://data.digitisingsocialcare.co.uk/browser/dataset/110069/0)

A downloadable version can be found in the Resources section of the Glossary.

Implementation Guidance

Conceptual Model

Introduction to the MODS

FHIR Profiles

Dedicated helpdesk for NHS Digital Social Care Record Assured Solution Suppliers

<p>The standard will support interoperability across a wide range of health and adult social care systems and ensure data collected supports the delivery of quality care services.</p>
<div style="padding:56.25% 0 0 0;position:relative;"><iframe src="https://player.vimeo.com/video/925164042?badge=0&amp;autopause=0&amp;player_id=0&amp;app_id=58479" frameborder="0" allow="autoplay; fullscreen; picture-in-picture; clipboard-write; encrypted-media; web-share" referrerpolicy="strict-origin-when-cross-origin" style="position:absolute;top:0;left:0;width:100%;height:100%;" title="Navigating Digital Assurance for Social Care Providers"></iframe></div>


The Digital Social Care Records Capabilities and Standards Roadmap

Core information standard

About Me

Personalised Care and Support Plan

Social Prescribing Information Standard

Urgent transfer from care home to hospital

NHS Data Model and Dictionary

NHS England Terminology Server

LGA Inform Plus

Unique Property Reference Number

SNOMED CT – UK Edition

HL7 FHIR UK Core

ISO 13606 - Electronic Health Record

openEHR

EN ISO 13940:2016 - A system of concepts for the continuity of care

ISO 3166 Country Codes

ISO 639-1 Language Codes

Digital Imaging and Communications in Medicine

NHSE-SD Data Catalogue

<span>This information standard is published under section 250 of the Health and Social Care Act 2012.</span>


<span>Under separate arrangements overseen by NHS England, implementing this Standard is a contractual requirement for all NHS England Digital Social Care Record (DSCR) Assured Solution Suppliers.</span>


Details about documents related to the person.

Document

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.

Review

Details about a health and social care admission.

Admission details

Details about a health and social care setting discharge.

Discharge details

A record of a communication or correspondence, including the status such as preparation, completed, stopped etc.

Communication

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.

Location

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.

Address

Abstract class. Contains information that should be included as part of any event record e.g. plan, assessment, observation etc.

Event

Record of occupancy and availability for a given location.

Occupancy

Information recorded when a person interacts with health and social care services and concerning the management of a persons care and those responsible for caring for them.

Administrative information

The process of evaluating a person’s needs, wishes, strengths, preferences and mental capacity, as well as identifying any relevant risks associated with them.

Assessment

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 plan

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.

About me

Assessment and planning information records.

Assessment and planning

Information about when a record was created, modified, completed and authorised and by whom.

Change log

Every record must be versioned and include following information to identify each version. If records are immutable, then changes can be inferred by examining each version of the record. Otherwise if they are not immutable, a detailed change log must be captured for every update to the record.

Versioned record

Every record must be versioned and a log created for every change to a record.

Audit information

A person who seeks to receive, is receiving, or has received care.

Subject of care

Health and social care third party having person role with the right to take decisions on behalf of the subject of care.

Proxy for subject of care

The details of the subject of care’s personal contacts and information about the relationship between the subject of care and the person.

Personal contact

Abstract class. Contains information that should be included as part of any person record e.g. subject of care, proxy, personal contact

Person

Unpaid person 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.

Unpaid carer

Information about a care worker who provides care for the subject of care. Usually an employee of a provider, local authority, healthcare organisation or voluntary organisation.

Care worker

Organisation involved in providing care and support.

Care organisation

Organisation or person participating in health and adult social care

Care actor

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.

Cardio-pulmonary resuscitation

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.

Informed consent

Details of the person's LPA record or equivalent

Lasting power of attorney

The framework of safeguards under the Mental Capacity Act 2005 for people who need to be deprived of their liberty in a hospital or care home in their best interests for care or treatment and who lack the capacity to consent to the arrangements made for their care or treatment.

Deprivation of Liberty Safeguards (DoLS) or equivalent

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).

Mental health act or equivalent

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 decision to refuse treatment (ADRT)

Written requests and preferences made by a person with capacity conveying their wishes, beliefs and values for their future care should they lose capacity.

Advance statement

Consent and legal information

Information about how care should be provided, including a set of planned / scheduled activities, as well as a record of the actions that have been completed and the outcomes of those actions.

Instruction

Defines a single activity within an Instruction, such as a medication administration.

Activity

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.

Action

Instructions, activities and actions performed by care actors for the subject of care

Instructions, Activities, Actions

An incident that occurred in relation to care services resulting in unexpected or avoidable death, harm or injury to patient, carer, staff or visitor.

Incident

Used to record observed circumstances that impact a person’s health and wellbeing.

Circumstances

Healthcare problems associated with the Subject of care.

Problem

All health and care needs, including emotional, social, cultural, religious and spiritual needs, should be included in assessments about the care and treatment people receive.

Need

Risks identified as part of a risk assessment

Risk

A record of a person's aspirations and a description of things they want someone supporting them to do (or not to do)

Wish

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.

Preference

A description of strengths and assets the person has relating to their goals and hopes about their health and well-being.

Strengths

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.

Alert

Details about the Subject of care's allergies or adverse reactions.

Allergies and adverse reactions

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.

Investigation result

End result, change or benefit for an individual who uses social care and support services.

Outcome

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.

Goal

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.

Safeguarding concern

Observation of activities relating to personal care and mobility about the home that are basic to daily living.

Daily living

A record of something a care actor has seen, heard, or noticed in reference to the health or social wellbeing of a person. These can include objective and subjective observations and can be recorded by healthcare professionals and/or other care actors.

Observations

Ensures a consistent baseline recording of direct care data by Care Quality Commission (CQC) registered adult social care providers.