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 Constrained Domain Model: AdmissionRelatedInformation

A constrained ENTRY containing a collection of data items required to represent the contemporary or retrospective activity of admitting a subject of care into a hospital provider spell. Comprises a single coded Admission Event item and optionally may contain:

  • an unbounded representation of the method by which the subject of care was admitted
  • the participation of an organisation or place entity as the location where the subject of care was admitted
  • the participation of an organisation or place entity as the source location from where the subject of care arrived for admission.
  • any coded representation of the reasons for admission which includes any presenting complaints, allergies or adverse reactions, procedures, or risks and goals.
  • any coded representation of the complaints presented which may or may not result in the reason for admission
  • a textual representation of the event

Specializes

GenericAdmissionEvent

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.Uuid.Ref 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 ReasonForAdmission 0 .. * HasAnnotation 0..1 Text

INDEPENDENT
IsConsequenceOf 0..* Diagnosis

RiskGoalsAndExpectations

ProcedureActivity

CareIssues

FindingObservation

INDEPENDENT
IsConsequenceOf 0..* Diagnosis

CareIssues

RiskGoalsAndExpectations

FindingObservation

ProcedureActivity

INDEPENDENT
items CareIssues 0 .. * 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 FindingObservation 0 .. * IsClinicalContextOf 0..* CareIssues

INDEPENDENT
IsIndicationOf 0..* StoppedMedicationActivity

CurrentMedicationActivity

ProcedureActivity

INDEPENDENT
HasAnnotation 0..* Text

INDEPENDENT
items AdmissionEvent 1 HasClinicalContext 0..* CareIssues

INDEPENDENT
HasContext 0..1 AdmissionMethod

DEPENDENT_OBJECT
HasAnnotation 0..* Text

INDEPENDENT
HasMotivation 0..* CareIssues

ProcedureActivity

AllergiesOrAdverseReactionEvent

RiskGoalsAndExpectations

INDEPENDENT
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 AdmissionMethod 0 .. 1
items AllergiesOrAdverseReactionEvent 0 .. * IsMotivationOf 0..* AdmissionEvent

INDEPENDENT
IsIndicationOf 0..* CurrentMedicationActivity

StoppedMedicationActivity

INDEPENDENT
HasAnnotation 0..* Text

INDEPENDENT
IsInterpretationOf 0..* AllergiesOrAdverseReactionPropensity

INDEPENDENT
items Text 0 .. *
items PresentingComplaint 0 .. * HasAnnotation 0..1 Text

INDEPENDENT
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 RiskGoalsAndExpectations 0 .. * IsMotivationOf 0..* AdmissionEvent

INDEPENDENT
HasAnnotation 0..* Text

INDEPENDENT

Participations

Other Participations

Name Class Occurs Description
other_participations AdmissionLocationParticpationChoice 0..1 Represents a choice of FUNCTIONAL_ROLE classes used to describe the participation of a ROLE class in a COMPOSITION. The ROLE class shall participate as a non-specific 'other participation' representing the location where the subject of care was admitted.
other_participations AdmissionSourceParticipationChoice 0..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' which states the roles that participate as the source location from where the subject of care arrived for admission.

Content of COMPOSITION Models

DischargeSummary

Reference Model Type

ENTRY