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.

Reference Model Class: ENTRY

The ENTRY class contains (as ITEMs) the information acquired and recorded for a single observation or observation-set (battery or time series), a single clinical statement such as a portion of the patient's history or an inference or assertion, or a single action that is intended or has actually been performed. An ENTRY may have zero ITEMs if it is a revision of an ENTRY previously recorded in error. By implication of the Reference Model, each and every ELEMENT instance within an ENTRY must share the same information provider (i.e. source of information) and refer to the same subject of information. The items collection of the ENTRY class is constrained for use by the LRA to contain member instances of type ELEMENT only.

Specializes

CONTENT

Attributes

Name Data type Occurs Description
act_id II 0..1 The identifier value of this attribute relates this ENTRY, if it documents an activity, to an act management or workflow system.
uncertainty_expressed BL.Null 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. The finding (or procedure) context values of the ENTRY's member ELEMENTs (expressed via the ELEMENT meaning attribute) may overlap with the semantics of uncertainty_expressed. This attribute therefore has a fixed value of nullFlavor = NA when used within the LRA.


Relationships

Name Class Occurs Description
other_participations FUNCTIONAL_ROLE 0..* This association represents any other agents who have contributed to the health or healthcare processes documented within this ENTRY. Within the LRA the members of the association role collection may be specified as being of type lra.technical.en13606.extended.PARTICIPATION to allow for the specification of the participation type and (optionally) participation time. However, because PARTICIPATION is an LRA-specific extension to EN 13606, any information specified by instances of the class is outside of the scope of interpretation by systems that conform to the general standard only.
info_provider FUNCTIONAL_ROLE 0..1 Person, software or device that has provided the information documented in this ENTRY. The agent need not be specified if the information source is implicit from the clinical context or the participants identified for the COMPOSITION.
items ITEM 0..* This association contains the data structure and values of the ENTRY. The items collection is constrained for use by the LRA to contain member instances of type ELEMENT only.
subject_of_information RELATED_PARTY 0..1 The relationship to the subject of care, and optionally the identifier, of the person or object about whom the information in this ENTRY relates.


Constraints

Type Name Specification
act_status is undefined in LRA LRA Invariant --Attribute act_status is undefined (i.e. value assignment is prohibited) inv: act_status.oclIsUndefined()
entry items may only contain elements LRA Invariant inv: items->forAll(i|i.oclIsKindOf(ELEMENT))
information_provider is of type FUNCTIONAL_ROLE LRA Invariant inv: information_provider.oclIsDefined() implies information_provider.oclIsTypeOf(FUNCTIONAL_ROLE)
meaning undefined LRA Invariant inv: meaning.oclIsUndefined()
name value LRA Inv: Fixed inv: name.value = <a href="$element://{99CDF407-1579-4eac-BB4F-F9D25CB6AA56}"><font color="#0000ff"><u>LraRecordComponentName</u></font></a>.ENTRY
no relationship type conflict in LRA LRA Invariant inv: items->select(meaning.oclIsTypeOf(CD) and meaning.codesystem = "OID for SNOMED") implies (subject_of_information.relationship.isNull() and subject_of_information.relationship.nullFlavour = DER)
subject_of_information_category no default in LRA LRA Invariant -- The default value stated in EN 13606-3:2008 for subject_of_information_category does not apply. inv: subject_of_information_category.oclIsUndefined() implies not (subject_of_information_category.code.value = SUBJECT_CATEGORY.DS00)
subject_of_information_category undefined in LRA LRA Invariant --Attribute subject_of_information_category is undefined (i.e. value assignment is prohibited) inv: subject_of_information_category.oclIsUndefined()
uncertainty expressed has nullFlavor LRA Invariant uncertainty_expressed.nullFlavor.oclIsDefined and uncertainty_expressed.nullFlavor = LraAnyNullFlavor.DER

Reference Model Type