Logical Record Architecture for Health and Social Care

Discharge Summary Release 0.02
Contents
The content of this release is not comprehensive and is not fully validated and must not be used in live system implementations.

ENTRY Domain Model: GenericProcedure

Logical Record Architecture for Health and Social Care > LRA Model Artefacts > Domain Models > ENTRY Domain Models > GenericProcedure

An ENTRY containing a collection of data items required to represent a generic procedure when it is not known explicitly what kind of procedure this is and excludes an investigation procedure or a product or substance related procedure. Comprises a single coded Generic Procedure and optionally may contain:

  • a textual description of the event
  • a coded representation of any medication activities that are relevant to the generic procedure.
  • a coded representation of any diagnosis, problems, and findings that may be an indication for the generic procedure
  • a coded representation of a generic procedure that may be included or occur concurrently to another generic procedure
  • a coded representation of a generic procedure that is performed to fulfill a goal.
Incorporates requirements from the following sources:
  • NPfIT MIM 7.2.02 Investigation template (COCD_TP146019UK04)
  • Section 3.12.4 of NPFIT-NCR-DES-0135.07 NHS Care Record Elements
2: 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 GenericFindingObservation 0..*
items Text 0..*
items GenericProblemAndIssue 0..*
items DiagnosisName 0..*
items GenericProcedure 1
items ProductOrSubstanceRelatedActivity 0..*
other_participations OtherParticipationsChoice 0..*


Reference Model Type

ENTRY