A constrained ENTRY containing a collection of data items required to represent any issues requiring health service or carer attention, or an admission issue that represents a patient want or requirement for help. The needs or related requirements to be resolved or noted are perceived as a problem or issue by a patient, carer or a Care Professional¹. Comprises a single coded Presenting Complaint and/or Problem and one or more ProblemsAndComplaints Tags to describe the type of problem (e.g. presenting complaint). Optionally may also contain:

• a textual description of the event

• any coded representations of findings, diagnosis, and procedures that have some clinical context with the generic problem or issue.
• any coded representation of an admission event that occurred because of the problem or presenting complaint
• any coded representation of a current or stopped medication activity that was initiated due to the problem or presenting complaint
• any coded representation of any risks, expectations or goals associated with the problem or presenting complaint.

Requirements obtained from ¹ LRA Discharge Summary Requirements Specification

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): 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	Diagnosis	0 .. *		IsComplicatedBy	0..*	Diagnosis ProcedureActivity	INDEPENDENT
				IsClinicalContextOf	0..*	CareIssues	INDEPENDENT
				IsIndicationOf	0..*	CurrentMedicationActivity StoppedMedicationActivity	INDEPENDENT
				HasRecordRole	0..1	DiagnosisStatus	INDEPENDENT
				HasAnnotation	0..*	Text	INDEPENDENT
items	Text	0 .. *
items	ProcedureActivity	0 .. *		IsComplicatedBy	0..*	ProcedureActivity FindingObservation	INDEPENDENT
				HasIndication	0..*	Diagnosis FindingObservation CareIssues	INDEPENDENT
				IsIndicationOf	0..*	StoppedMedicationActivity CurrentMedicationActivity	INDEPENDENT
				HasAnnotation	0..*	Text	INDEPENDENT
				Complicates	0..*	Diagnosis	INDEPENDENT
items	CurrentMedicationActivity	0 .. *		HasTemporalContext	0..*	MedicationFutureCourseTiming MedicationCourseTiming	INDEPENDENT
				HasRecordRole	0..*	CurrentMedicationReconciliationStatus	INDEPENDENT
				HasTemporalContext	0..*	CurrentMedicationActivity	INDEPENDENT
				HasParameterSetting	0..*	DoseQuantity	INDEPENDENT
				AssertsTiming	0..*	EventDoseFrequency MeasuredDoseFrequency MedicationReviewText	INDEPENDENT
				Consumes	1..*	MedicinalProductOrSubstance	INDEPENDENT
				HasAnnotation	0..*	DosageInstructions	INDEPENDENT
				UsesDevice	0..*	MedicinalDevice ComplianceDevice	INDEPENDENT
				IsProspectOf	1..*	MedicationRecommendationActivity	INDEPENDENT
				IsPrecedentOf	1..*	StoppedMedicationActivity	INDEPENDENT
				HasAnnotation	0..*	DosageInstructions AdditionalInstructions	INDEPENDENT
				HasIndication	0..*	AllergiesOrAdverseReactionEvent TreatmentActivity InvestigationActivity FindingObservation CurrentMedicationActivity ReasonForMedicationText PropertyObservation ProcedureActivity CareIssues Diagnosis	INDEPENDENT
				IsComponentActionOf	0..*	CurrentMedicationActivity TreatmentActivity	INDEPENDENT
				HasComponentAction	0..*	MedicationReviewActivity	INDEPENDENT
items	CareIssues	1		IsClinicalContextOf	0..*	AdmissionEvent	INDEPENDENT
				HasRecordRole	0..*	ProblemsAndComplaintsTag	INDEPENDENT
				HasClinicalContext	0..*	ProcedureActivity Diagnosis FindingObservation	INDEPENDENT
				IsIndicationOf	0..*	StoppedMedicationActivity CurrentMedicationActivity	INDEPENDENT
				IsMotivationOf	0..*	ProcedureActivity AdmissionEvent	INDEPENDENT
				HasAnnotation	0..*	Text	INDEPENDENT
items	ProblemsAndComplaintsTag	0 .. *
items	StoppedMedicationActivity	0 .. *		HasRecordRole	0..*	StoppedMedicationReconciliationStatus	INDEPENDENT
				HasAnnotation	0..*	Text	INDEPENDENT
				HasTemporalContext	0..*	StoppedMedicationActivity	INDEPENDENT
				IsComponentActionOf	0..*	StoppedMedicationActivity TreatmentActivity	INDEPENDENT
				HasPredecessor	1..*	CurrentMedicationActivity	INDEPENDENT
				HasIndication	0..*	ReasonForStoppingMedicationText ProcedureActivity FindingObservation PropertyObservation AllergiesOrAdverseReactionEvent StoppedMedicationActivity InvestigationActivity Diagnosis CareIssues TreatmentActivity	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	FindingObservation	0 .. *		IsClinicalContextOf	0..*	CareIssues	INDEPENDENT
				IsIndicationOf	0..*	StoppedMedicationActivity CurrentMedicationActivity ProcedureActivity	INDEPENDENT
				HasAnnotation	0..*	Text	INDEPENDENT

Participations

Other Participations

Name	Class	Occurs	Description
other_participations	ProblemAndComplaintResponsibilityChoice	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 as a non-specific 'other participation' representing the person who is responsible for recording the problem about the subject of care.

Content of COMPOSITION Models

DischargeSummary

Reference Model Type

ENTRY