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.

ELEMENT Domain Model: GenericAssessment

An ELEMENT to represent the procedure of assessing the subject of care or an area/subject that is relevant to his/her care.

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): GENERAL_ACTIVITY_ELEMENT
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.
meaning CD.CV.SCT 1..1 A coded representation of the type of assessment performed (or to be performed).

code
Semantic expression constraint
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
obs_time IVL_TS 0..1 The date and time, or interval, of the assessment.
value ANY 1..1 An ELEMENT has a single DATA_VALUE containing the value, unless this is indicated as absent by a null_flavour attribute.



COMPONENT RELATIONSHIPS

Subject of relationships

Name Object of relationship Occurs Dependency
HasPart BloodPressureObservation 0..* INDEPENDENT
HasPart PulseRateObservation 0..* INDEPENDENT
HasPart ProductOrSubstanceRelatedActivity2 0..* INDEPENDENT
HasPart MaterialFlowRate 0..* INDEPENDENT
HasPart GenericPropertyObservation 0..* INDEPENDENT
HasPart GenericFindingObservation 0..* INDEPENDENT
HasPart GenericProcedure 0..* INDEPENDENT
HasPart ProductOrSubstanceRelatedActivity 0..* INDEPENDENT
HasPart GenericInvestigation 0..* INDEPENDENT
HasPart GenericTreatment 0..* INDEPENDENT
HasComponentAction GenericAssessment 0..* DEPENDENT_OBJECT
HasContext GenericDiscussion 0..* INDEPENDENT
HasAnnotation Text 0..* INDEPENDENT
HasReason UnboundData 0..* INDEPENDENT
HasReason GenericFindingObservation 0..* INDEPENDENT
HasOutcome GenericAssessment 0..* INDEPENDENT
HasOutcome GenericFindingObservation 0..* INDEPENDENT
HasOutcome GenericTreatment 0..* INDEPENDENT
HasClinicalContext GenericFindingObservation2 0..* INDEPENDENT
HasClinicalContext GenericFindingObservation 0..* INDEPENDENT


Object of relationships

Name Subject of relationship Occurs Dependency
HasIndication GenericAdmissionEvent 0..* INDEPENDENT
HasProspect RecommendationActivity 0..* INDEPENDENT
HasIndication GenericAdmissionEvent2 0..* INDEPENDENT
HasClinicalContext GenericAdmissionProspect 0..* INDEPENDENT
HasOutcome GenericAssessment 0..* INDEPENDENT
HasComponentAction GenericAssessment 0..* DEPENDENT_OBJECT
HasIndication GenericTreatment 0..* INDEPENDENT

Item of ENTRY Domain Models

GenericAdmissionEvent

GenericAdmissionEvent2

GenericAdmissionProspect

GenericAssessment

GenericTreatment

Reference Model Type

INVESTIGATION_ACTIVITY_ELEMENT