An ENTRY containing a collection of data items required to represent the needs or related requirements to be resolved or noted, and are perceived as a problem or issue by a patient, carer or a Care Professional¹. Comprises a single coded Generic Problem and Issue and one or more ProblemAndIssue 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 generic problem or issue
• any coded representation of a product or substance related activity that was initiated due to the generic problem or issue
• any coded representation of any risks, expectations or goals associated with the generic problem or issue.

Requirements obtained from ¹ LRA Discharge Summary Requirements Specification ² NPFIT-NCR-DES-0135.07 NHS Care Record Elements

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

Name	ELEMENT Class	Occurs	Description
items	ProblemAndIssueTag	0..*
items	GenericProblemAndIssue	1
other_participations	OtherParticipationsChoice	0..*
items	GenericAdmissionEvent	0..*
items	DiagnosisName	0..*
items	GenericProcedure	0..*
items	ProductOrSubstanceRelatedActivity	0..*
items	Text	0..*
items	GenericFindingObservation	0..*
items	RisksExpectationsOrGoals	0..*

Reference Model Type

ENTRY