Logical Record Architecture for Health and Social Care

Discharge Summary Release 0.02
Contents

Requirements Specification for GP Details

The details of the GP and the GP practice to whom the discharge summary of the patient has to be sent for follow up care within the primary care setting. Requirement References: - A Clinician’s Guide to Record Standards – Part 2: Standards for the structure and content of medical records and communications when patients are admitted to hospital (Academy of Medical Royal Colleges, October 2008). - Keeping patients safe when they transfer between care providers – getting the medicines right, Part 1: Good practice guidance for health professions, Royal Pharmaceutical Society (Final Draft 06/06/2011).

GP Name

Business Definition

The name of the patient’s usual GP.

Requirement Reference

- A Clinician’s Guide to Record Standards – Part 2: Standards for the structure and content of medical records and communications when patients are admitted to hospital (Academy of Medical Royal Colleges, October 2008). - Keeping patients safe when they transfer between care providers – getting the medicines right, Part 1: Good practice guidance for health professions, Royal Pharmaceutical Society (Final Draft 06/06/2011).

Proposed Data Values

[Prefixes][Given names][Family names][Suffixes].

Data Use

Target for communication.

Data Source

PAS, PDS.

Available Data Standards

ISO 21090 Health informatics data types, HL7 V3 Data Types, NHS MIM data types.

GP Code

Business Definition

Unique identifier for the patient's usual GP.

Requirement Reference

LRA expert group discussion 2011 – to support efficient electronic routing within GP practices. It was noted that current practice, despite national policies, still supported patient relationships with individual GPs, and not only to whole GP practices.

Proposed Data Values

Unique GP identifier code.

Data Use

Target for communication (particularly for electronic routing to an individual within a GP practice).

Data Source

PAS.

Available Data Standards

Organisation Data Service code.

GP Practice Code

Business Definition

Unique identifier which defines the patient's registered GP practice.

Requirement Reference

A Clinician’s Guide to Record Standards – Part 2: Standards for the structure and content of medical records and communications when patients are admitted to hospital (Academy of Medical Royal Colleges, October 2008).

Proposed Data Values

Unique GP practice identifier code (with associated name).

Data Use

Target for communication.

Data Source

PAS.

Available Data Standards

Organisation Data Service code.

GP Practice Address

Business Definition

The address of the patient’s registered GP practice.

Requirement Reference

A Clinician’s Guide to Record Standards – Part 2: Standards for the structure and content of medical records and communications when patients are admitted to hospital (Academy of Medical Royal Colleges, October 2008).

Proposed Data Values

Address Prefix, Building Name and Building Number; Dependent Street or Road Name, and Street or Road Name; Dependent Locality and Double dependent locality; Postal Town; Postal County; Postal Code; PAF Key - unique ID for an address allocated by the Royal Mail.

Data Use

Target for communication.

Data Source

PAS.

Available Data Standards

BS7666 address standard, e-GIF, NHS ISB 1500: Common User Interface - Address Input and Display.