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.

COMPOSITION: SrfTestComposition

A COMPOSITION represents the set of RECORD_COMPONENTs composed (authored) during one clinical encounter or documentation session, and committed within one EHR.

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.
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. Within the LRA, this attribute is used by the COMPOSITION class to provide a coded representation of the type of composition, e.g. Progress note, Laboratory test result form, Radiology report, Referral letter, Clinic visit, Clinic letter, Discharge summary, etc.

code
Semantic expression constraint
rc_id II.Uuid 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
Literal value(s):
session_time IVL_TS 1..1 The date and time or interval during which the clinical encounter or documentation session occurred.


Contained ENTRYs

Name ENTRY Class Occurs Description
content SrfTestAdmissionDetails 1..1


Participations

Committal Information

Name Class Occurs Description
committal SrfTestCommittalAuditInfo 1..1

Other Participations

Name Class Occurs Description
other_participations SrfTestRecordTargetChoice 1..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 <please complete>.

Reference Model Type

COMPOSITION