Logical Record Architecture for Health and Social Care

Discharge Summary Release 0.02
Contents

Requirements Specification for GP Advice Recommendations And Future Plan

Actions advised or recommended to the GP. To include: - Action (e.g. specific actions, pending investigations and results, outstanding issues, HRT and cervical screening). - Person responsible - Appropriate date and time - Suggested strategies for potential problems, e.g. telephone contact for advice [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)]. Includes ‘any immediate post-discharge requirement from the primary healthcare team’ (2011/12 Standard Terms and Conditions for Acute Hospital Services (Department of Health, April 2011)).

GP Actions

Business Definition

Action suggestions directed to the GP by the hospital at the time of discharge of the patient. These may include a clinical review to be performed (e.g. BP check, investigations, etc), a prescribing review (based on medication recommendations and discharge medications prescribed), vaccination, referral to another service, strategies for potential problems, etc.

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). - 2011/12 Standard Terms and Conditions for Acute Hospital Services (Department of Health, April 2011).

Proposed Data Values

Coded value (free text as exception).

Data Use

Patient information and continuing care.

Data Source

Copied from previous record or new entry.

Date For Actions

Business Definition

The date(s) and optionally time when the action is planned to be executed.

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

A string with the format "YYYYMMDDHHMMSS.UUUU[+|-ZZzz]".

Data Use

Patient information, continuing care.

Data Source

Copied from previous record or new entry.

Available Data Standards

ISO 11404 - Point in Time, NHS ISB 1502: Common User Interface - Date and Time Input, NHS ISB 1503: Common User Interface - Date Display, NHS ISB 1501: Common User Interface - Time Display.

Comments

Business Definition

Opportunity to record additional information about the future action. May include the status of the action in terms of Booked, Proposed or Requested.

Requirement Reference

LRA DS expert group 2011 – potentially useful for added detail, at the author’s discretion.

Proposed Data Values

Free text.

Data Use

Patient information, continuing care.

Data Source

Copied from previous record or new entry.