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: CareIssues

An ELEMENT to represent an issue requiring health service or carer attention. An issue may result in the admission of a patient to hospital. May include problems, and other issues as perceived by the patient, carer or care professional.

Specializes

GenericProblemAndIssue

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): FINDING_OBSERVATION_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 The standardised clinical or administrative concept to which the name attribute has been mapped. In archetyped systems it will correspond to the archetype node name. In non-archetyped systems it might be a coded term from an appropriate terminology system.
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 ITEM actually occurred or was true, if different from the session time of the COMPOSITION.
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

Subject Relationships

Object Class Name Occurs Dependency Specified by
Text HasAnnotation 0..* INDEPENDENT CareIssues
ProcedureActivity HasClinicalContext 0..* INDEPENDENT CareIssues
Diagnosis
FindingObservation
ProblemsAndComplaintsTag HasRecordRole 0..* INDEPENDENT CareIssues
AdmissionEvent IsClinicalContextOf 0..* INDEPENDENT CareIssues
StoppedMedicationActivity IsIndicationOf 0..* INDEPENDENT CareIssues
CurrentMedicationActivity
ProcedureActivity IsMotivationOf 0..* INDEPENDENT CareIssues
AdmissionEvent

Object Relationships

Subject Class Name Occurs Dependency Specified by
ReasonForAdmission IsConsequenceOf 0..* INDEPENDENT ReasonForAdmission
ReasonForAdmission IsConsequenceOf 0..* INDEPENDENT ReasonForAdmission
AdmissionEvent HasClinicalContext 0..* INDEPENDENT AdmissionEvent
AdmissionEvent HasMotivation 0..* INDEPENDENT AdmissionEvent
CurrentMedicationActivity HasIndication 0..* INDEPENDENT CurrentMedicationActivity
Diagnosis IsClinicalContextOf 0..* INDEPENDENT Diagnosis
FindingObservation IsClinicalContextOf 0..* INDEPENDENT FindingObservation
ProcedureActivity HasIndication 0..* INDEPENDENT ProcedureActivity
StoppedMedicationActivity HasIndication 0..* INDEPENDENT StoppedMedicationActivity

Item of ENTRY Constrained Domain Models

AdmissionRelatedInformation

CareIssues

CurrentMedicationActivity

Diagnosis

DischargeDetails

ProcedureActivity

StoppedMedicationActivity

Reference Model Type

FINDING_OBSERVATION_ELEMENT