Logical Record Architecture for Health and Social Care

Discharge Summary Release 0.02

The content of this release is not comprehensive and is not fully validated and must not be used in live system implementations.

ELEMENT Domain Model: UnboundGenericFinding

An ELEMENT to represent an unbound generic finding. Findings are observations about a patient made by a Care Professional, patient, or a carer. These include information provided by the patient or carer, clinical observations, clinical findings on examination, investigation results and administrative findings3. An unbound finding is a finding that is unable to be described by (i.e. bound to) SNOMED CT. 3: NPFIT-NCR-DES-0422.06 Representation of Commonly Used Concepts in the Care Record

Attributes

Name Data type Occurs Description Value Constraints
name SC 1..1 The name, expressed as a coded value or as plain text, specifies the clinical or administrative concept to which this EHR node corresponds, as labelled in the EHR system in which it was first committed.

value
Literal value(s): UNBOUND_DATA_ELEMENT
rc_id II 1..1 The globally-unique identifier by which this node in the EHR hierarchy is referenced in the EHR system to which the data were first committed. This identifier shall be retained by the EHR Recipient and re-used whenever this RECORD_COMPONENT is subsequently included in another EHR_EXTRACT.
synthesised BL 1..1 This attribute value shall be TRUE if this RECORD_COMPONENT has been created in order to comply with this standard , but this point in the EHR hierarchy has no corresponding node in the EHR from which it was extracted.

obs_time IVL_TS 0..1 The date and time, or interval, of the unbound generic finding.
value ANY 1..1 Describes the unbound generic finding. This may be in a textual or coded format. Coded formats shall not be described using SNOMED CT.


COMPONENT RELATIONSHIPS

Object of relationships

Name Subject of relationship Occurs Dependency
HasClinicalContext BodyHeightMeasurement 0..* DEPENDENT_OBJECT
HasClinicalContext BodyHeightObservation 0..* DEPENDENT_OBJECT
HasClinicalContext BodyWeightMeasurement 0..* DEPENDENT_OBJECT
HasClinicalContext BodyWeightObservation 0..* DEPENDENT_OBJECT
HasClinicalContext TemperatureMeasurement 0..* DEPENDENT_OBJECT
HasClinicalContext TemperatureObservation 0..* DEPENDENT_OBJECT

Item of ENTRY Domain Models

BodyHeight

BodyWeight

Temperature

Reference Model Type

UNBOUND_DATA_ELEMENT