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Professional Records Standards Body

Professional Records Standards Body

The Professional Record Standards Body was established in 2013 to develop clinical standards for health and care records. We are a community interest company and as such our core aim is not commercial. The PRSB has a robust and sustainable business model to support its open and inclusive working methods.

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About me

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Professional Standards Records Body

About Me information is the most important details that a person wants to share with professionals in health and social care. This information might include how best to communicate with the person, how to help them feel at ease or details about how they like to take their medication. The PRSB has published a standard outlining how About Me information should be documented and shared in health and care records.

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Further information

Definition

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How I communicate and how to communicate with me

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PRSB Standard: About Me

A description of how you communicate normally including any communication aids you use, for example a hearing aid.

Include your preferred language of communication, if your first language is not English.
Include how you would communicate when you are in pain or distress.
Include how you communicate choices.
Include how you give feedback or raise a concern.
Include how you like to receive information
Describe how you would like others to engage and communicate with you, including how you would like to be addressed.

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Definition

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How and when to support me

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PRSB Standard: About Me

A description of how and when you want someone caring for you to support you.

This could include support needs in an emergency situation (for example taking blood)

This could include support you need to maintain important routines or to carry out particular activities, for example: - Personal care routines, Eating and drinking, Bedtime routines, Taking medications, Moving and transitioning

This could also include support needed with:- wearing glasses/hearing aids/false teeth etc, making informed choices or understanding dangers and risks, managing your emotions, moods and behaviours, memory or confusion.

Include how your support needs change in different environments. Include any triggers that might result in you needing further support and strategies for avoiding or addressing the triggers. Include how you want the support to be provided.

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Data descriptor

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Immigration status

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PRSB Standard: Hospital referral for assessment for community care and support, v1.1 - Implementation guidance

The immigration status of the person, their permissions to live and receive care and support in the UK e.g. asylum seeker, indefinite leave to remain in the UK.

Immigration status is required, where available, for the sole purpose of assisting the local authority in deciding if the person is eligible for funded social care. Utilise the national codes. Include start date, end date and any comments.

Code:
1. Asylum Seeker
2. Exceptional leave to remain in UK
3. Indefinite leave to remain in UK
4. Limited leave to remain in UK
5. No Recourse to Public Funds (NRPF)
6. Other nationals
7. Refugee
8. Unaccompanied Asylum Seeker
9. EU pre-settled status
10. EU settled status

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Definition

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My wellness

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PRSB Standard: About Me

A description covering what you are able to do, how you engage with others and how you feel on a typical day through to on a day when you are unwell or really unwell.

Include any causes that might result in you becoming unwell and strategies for avoiding or addressing the causes. For example, not drinking enough water could cause constipation.
Include any signs that indicate you might be becoming unwell.
On a bad day describe what is different about what you are able to do, how you engage with others and how you feel.
Include how your everyday life is affected by any medical conditions e.g. dementia and any symptoms e.g. itchiness, cough, pain and how you manage those conditions.
Include past health issues or experiences that need to be considered
Include your wellbeing and lifestyle goals and aspirations

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Definition

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PRSB Personalised Care and Support Planning Standard

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Professional Records Standards Body

Personalised care planning standards will help to enable people to manage their own care, with the support of a wide range of services including GPs, hospitals, occupational therapy and social care. This new standard will help citizens and health and care professionals get the right information when they need it, in order to personalise care, and improve the experience for the patient, their carer and their families.

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Definition

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People who are important to me

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PRSB Standard: About Me

Details of who is important to you and why. They could be family members, carers, friends, members of staff etc. Include how you want the people important to you to be engaged and involved in your care and support in both emergency and normal situations. Include how you stay connected to the people important to you. Who should not be contacted or consulted about your care and support and why, if you wish to say

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Definition

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Please do and please don't

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PRSB Standard: About Me

A description of things you want someone supporting you to do or not to do.

For example, this might include: - Talk to me not to my carer, remind me to take my medication, encourage me to wash my hands regularly, explain to me what is happening and why, respond to my communication.

A description of things you do not want someone supporting for you to do. For example, this might include: - Discussing or asking questions about certain topics, making assumptions about something, providing support when it is not wanted, talking to you in a certain way.

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Shared decision making

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Professional Records Standards Body

The PRSB information standard on shared decision making provides a framework for clinicians to record the decision-making process between themselves and their patients. The standard also allows the shared decision information to be shared between professionals and their different record systems. The standard has been developed based on the GMC guidance on shared decision-making and consent and the NICE guidelines.

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Definition

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What is most important to me

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PRSB Standard: About Me

A description of what is most important to you

Emergency Information : - Include any essential information that any professional in health and social care should know about the you in any situation, including emergencies.

Other Information : - This could include : - Values, Spirituality/religion, Ethnicity, Culture, Pets, Goals and aspirations, Meaningful activities including leisure activities, visiting places, sport and exercise, listening to music, employment, education, volunteering

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