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Adult Social Care Digital Social Care Record: Minimum Operational Data Standard (MODS): Implementation Guidance

Observation (page 16 of 9) in Conceptual Model: Adult Social Care Record (chapter 8 of 10) within Adult Social Care Digital Social Care Record: Minimum Operational Data Standard (MODS): Implementation Guidance

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.

%%{ init: { 'theme': 'base' } }%% 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" --> ObservationTypes SubjectOfCare -- "1 refers to 0..*" --> Observation CareActor -- "1 records 0..*" --> Observation Observation -- "0..* involves 0..*" --> CareActor Observation -- "1..* performed in 1" --> Location %% Downstream Influences Observation -- "influences 0..*" --> Review Observation -- "influences 0..*" --> CarePlan[Care Plan] Observation -- "influences 0..*" --> Assessment Observation -- "influences 0..*" --> Instruction

Observations are recorded by a Care Actor and refer to the Subject of care.

An Observation is performed in a Location and multiple Care Actors could be involved. Observations influence Assessments, Care plans and Instructions, as well as being a trigger for Reviews.

Observations recorded as part of social care provision including:

Needs Risks Safeguarding concerns Strengths Wishes Preferences Daily Living Alert Incident Circumstance (including Environment) Outcome Some Observations would typically be recorded as part of healthcare provision such as:

Page last updated: 13 July 2026