An ENTRY containing a collection of data items required to represent 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 findings¹. The class comprises a single coded Generic Finding Observation and optionally may contain:

• a textual description of the finding
• a coded representation of any property observations that is derived from the finding.
• a coded representation of any procedure or product activity which may occur due to the finding

• a coded representation of the interpretation of a diagnosis

Incorporates requirements from the following sources:

• LRA Discharge Summary Requirements Specification v0.4
• NPFIT-NCR-DES-0135.07 NHS Care Record Elements [Section 3.9]

¹ NPFIT-NCR-DES-0135.07 NHS Care Record Elements

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): ENTRY
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.	value Default value: false
uncertainty_expressed	BL	1..1	This attribute is set to TRUE to advise the EHR Recipient that this ENTRY contains data that indicates some degree of uncertainty, and that care should be taken when using these data within automated processes and systems.	nullFlavor Literal value(s): NA

Contained ELEMENTs

Graphical Representation

Name	ELEMENT Class	Occurs	Description
items	GenericProblemAndIssue	0..*
items	GenericProcedure	0..*
items	Text	0..*
items	GenericPropertyObservation	0..*
items	RisksExpectationsOrGoals	0..*
items	ProductOrSubstanceRelatedActivity	0..*
items	DiagnosisName	0..*
items	GenericFindingObservation	1..*

Reference Model Type

ENTRY