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 Constrained Domain Model: DiagnosisStatus

A constrained ELEMENT to represent one or more status that a particular diagnosis may have at any given point in time. This may include primary or discharge diagnoses, and relevant previous diagnoses including complications and comorbid conditions. The Diagnosis Status tag represents the administrative or process-related type of the associated diagnosis (e.g. primary diagnosis, admission diagnosis, discharge diagnosis etc), but not the clinical condition diagnosed1. The scope of a Diagnosis Tag is indicated by its relationship with other record components. For example, the Diagnosis Tag representing the primary discharge diagnosis of a hospital stay is linked to a component representing that hospital stay1. Changes to the diagnosis ascribed to a particular category are represented by creating links between a Diagnosis Tag and a different Diagnosis Name and marking the existing links as invalid1. Progress of a Diagnosis Name (e.g. from an admission diagnosis to a primary discharge diagnosis) is represented by creating a new link to the appropriate Diagnosis Tag1. 1: NPFIT-FNT-TO-DPM-0931.05 SNOMED CT Bindings for Common Recording Patterns

Specializes

DiagnosisTag

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): RECORD_ARTEFACT_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.
meaning CD.CV.SCT 1..1 A coded representation of the type of diagnosis (e.g. primary diagnosis, admitting diagnosis).
code
Semantic expression constraint
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
obs_time IVL_TS 0..1 The date and time, or interval, at which the Diagnosis Tag is applicable.
value ANY 1..1 An ELEMENT has a single DATA_VALUE containing the value, unless this is indicated as absent by a null_flavour attribute.
nullFlavor
Literal value(s): NA


Component Relationships

Object Relationships

Subject Class Name Occurs Dependency Specified by
Diagnosis HasRecordRole 0..1 INDEPENDENT Diagnosis

Item of ENTRY Constrained Domain Models

Diagnosis

Reference Model Type

RECORD_ARTEFACT_ELEMENT