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: RisksGoalsAndExpectations

A constrained ENTRY containing a collection of data items required to represent the risks, expectations and goals of a subject of care or third party. Comprises a coded representation of the concerns, expectations and wishes and optionally:

  • a textual representation of the event.
  • a coded representation of the motivation for the admission of the subject of record.

Specializes

RisksExpectationsAndGoals

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 RiskGoalsAndExpectations 1 IsMotivationOf 0..* AdmissionEvent

INDEPENDENT
HasAnnotation 0..* Text

INDEPENDENT
items AdmissionEvent 0 .. * HasClinicalContext 0..* CareIssues

INDEPENDENT
HasContext 0..1 AdmissionMethod

DEPENDENT_OBJECT
HasAnnotation 0..* Text

INDEPENDENT
HasMotivation 0..* CareIssues

ProcedureActivity

AllergiesOrAdverseReactionEvent

RiskGoalsAndExpectations

INDEPENDENT
items Text 0 .. *

Content of COMPOSITION Models

DischargeSummary

Reference Model Type

ENTRY