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.

ENTRY Constrained Domain Model: DischargeDetails

A constrained ENTRY containing a collection of data items required to represent the contemporary or retrospective activity of discharging a subject of care from a hospital provider spell. Comprises a single coded Discharge Event item and optionally may contain:

  • an unbounded representation of the method by which the subject of care was discharged
  • an indication whether the subject of care lives alone and may/may not require help post discharge
  • the participation of an organisation or place entity as the destination location of the subject of care after discharge
  • the healthcare professional (i.e. the consultant) primarily responsible for the discharge of the subject of care.

Specializes

GenericDischargeEvent

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

Subject ELEMENT class Related object classes
Name ELEMENT Class Occurs Description Relationship Occurs Class Dependency
items DischargeMethod 0 .. *
items CareIssues 0 .. * IsClinicalContextOf 0..* AdmissionEvent

INDEPENDENT
HasRecordRole 0..* ProblemsAndComplaintsTag

INDEPENDENT
HasClinicalContext 0..* ProcedureActivity

Diagnosis

FindingObservation

INDEPENDENT
IsIndicationOf 0..* StoppedMedicationActivity

CurrentMedicationActivity

INDEPENDENT
IsMotivationOf 0..* ProcedureActivity

AdmissionEvent

INDEPENDENT
HasAnnotation 0..* Text

INDEPENDENT
items LivesAloneFinding 0 .. 1
items DischargeEvent 1 HasContext 0..1 DischargeMethod

LivesAloneFinding

INDEPENDENT

Participations

Other Participations

Name Class Occurs Description
other_participations DischargeResponsibilityChoice 0..1 Represents a choice of FUNCTIONAL_ROLE classes used to describe the participation of a ROLE class in a COMPOSITION or an ENTRY. The ROLE class shall participate as a non-specific 'other participation' representing the person who is responsible for the discharge of the subject of care.
other_participations DischargeDestinationChoice 0..1 Represents a choice of FUNCTIONAL_ROLE classes used to describe the participation of a ROLE class in a COMPOSITION. The ROLE class shall participate as a non-specific 'other participation' representing the destination or place where the subject of care is being discharged to.

Content of COMPOSITION Models

DischargeSummary

Reference Model Type

ENTRY