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.

ENTRY Domain Model: GenericInvestigation

An ENTRY containing a collection of data items required to represent a procedure undertaken to find out more information about a patient's state of health or wellbeing2. Comprises a single coded Generic Investigation and optionally may contain:

  • a textual description of the event
  • a coded representation of any medication activities that are relevant to the investigation.
Incorporates requirements from the following sources:
  • NPfIT MIM 7.2.02 Investigation template (COCD_TP146019UK04)
  • Section 3.12.4 of NPFIT-NCR-DES-0135.07 NHS Care Record Elements
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 Text 0..*
items ProductOrSubstanceRelatedActivity 0..*
items GenericInvestigation 1


Participations

Subject of Information

Name Class Occurs Description
SubjectOfInformationChoice 0..1 Represents a choice of RELATED_PARTY classes used to describe the participation of a ROLE class in an ENTRY. The ROLE class shall participate as the Subject of Information.

Information Provider

Name Class Occurs Description
InformationProviderChoice 0..1 Represents a choice of FUNCTIONAL_ROLE classes used to describe the participation of a ROLE class in an ENTRY. The ROLE class shall participate as an Information Provider (a.k.a. Informant).

Other Participations

Name Class Occurs Description
OtherParticipationsChoice 0..* 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 follows:
  • as a non-specific 'other participation'. This option is applicable when it is not relevant to explicitly state the participation type or when the source system is unable to support further specification of the participation type.
  • as any other explicitly stated participation type from the relevant vocabulary. This option shall not be used to describe a participation type of Information Provider (a.k.a. Informant), Composer (a.k.a. Author), or Attester (a.k.a Verifier).

Reference Model Type

ENTRY