Logical Record Architecture for Health and Social Care

Discharge Summary Release 0.02
Contents

Requirements Specification for All Current Diagnoses At Discharge

Primary diagnosis, secondary diagnoses and relevant previous diagnoses, including complications. [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).] NOTE: The LRA DS expert group advised that classifications of ‘primary’ and ‘secondary’ diagnoses were not useful to DS recipients (e.g. not used by GPs) and were also based on the perspective of a particular responsible specialty (and so will change if the responsible specialty department changes during the hospital stay). On this basis, references to primary and secondary diagnoses are not included in this specification. Diagnoses are decisions arrived at as a result of a synthesis of signs, symptoms, investigations (i.e. findings), and theoretical knowledge. These include diseases, disorders, syndromes and physiological states such as pregnancy. [NPFIT-NCR-DES-0135.07 NHS Care Record Elements]. All diagnoses current at the time of discharge and any diagnoses that were resolved during this admission. It is proposed that the following data may be documented for each diagnosis at discharge.

Diagnosis

Business Definition

A description of a diagnosis that is present at the time of discharge. Diagnoses are ‘labels for communication which after consideration include all relevant diseases, disorders and syndromes’ (from Headings for Communicating Clinical Information from the Personal Health Record: A Position Paper, Crown Copyright June 1998). The level of detail provided in this description is at the author’s discretion.

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). - Requirement for ‘a summary of the key diagnosis made during the Patient’s admission’ from 2011/12 Standard Terms and Conditions for Acute Hospital Services (Department of Health, April 2011).

Proposed Data Values

Coded expression including Name and other descriptor, qualifiers or status modifiers. The intent is to use codes wherever applicable (to allow automated record updates and analyses), but where authors want to add free text annotation, this should also be supported. Where no appropriate code exists, this value should be free text. (Note that free text data would not be accessible to automated interpretation). - Name - Site - Laterality - Episode * First episode * New episode * Old episode * Ongoing episode - Clinical Course * Acute * Chronic * Transitory - Severity * Mild * Moderate * Severe - Status (assumed to cover both the degree of certainty and the presence/absence of conditions of significance to diagnostic/comorbidity labelling): * Known present * Known absent * Suspected * NOT suspected * Definitely/confirmed present * Definitely NOT present/excluded/ruled out * Probably/possibly present * Probably NOT present

Data Use

Information for patients and care providers, updates to the patient’s primary or shared care records, use in primary care decision support algorithms Note: The values proposed for clinical severity are those currently in use in UK GP systems today. These values may be encoded to support efficient and readable human record-keeping, but further guidance and training is likely necessary to enable very precise and consistent clinical interpretations. Designers of decision support systems must apply discretion about the use of this data based on the reliability of its interpretation. Some clinical specialties may have fully-specified severity scoring frameworks, and these may be referenced in the LRA in future versions.

Data Source

Copied from previous record entry.

Data Examples

- Acute myocardial infarction, first, confirmed present - Carcinoma of hepatic flexure, probably present, first episode - Diabetes mellitus - Asthma - Chronic obstructive pulmonary disease - RULED OUT ulcerative colitis

Available Data Standards

SNOMED CT.

Date Diagnosis Made

Business Definition

The date and time when the diagnosis was made.

Requirement Reference

LRA DS expert group 2011 – useful to know for follow-up care when the diagnosis was determined.

Proposed Data Values

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

Data Use

Patient and care provider information.

Data Source

Copied from previous record 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.

Responsible Person

Business Definition

Person responsible for making the diagnosis.

Requirement Reference

LRA DS expert group 2011 – useful for follow-up contact.

Proposed Data Values

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

Data Use

Follow-up contact.

Data Source

PAS.

Available Data Standards

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

Responsible Consultant Treatment Specialty

Business Definition

Treatment Speciality is based on specialty, but also includes approved sub-specialties and treatment specialties used by hospital consultants.

Requirement Reference

LRA DS expert group 2011 – useful as context to the diagnosis.

Proposed Data Values

Treatment Speciality code.

Data Use

Follow up care.

Data Source

PAS.

Available Data Standards

NHS Hospital Episode Statistics ‘Treatment Specialty’.

Complication Aetiology

Business Definition

The diagnosis or procedure that was the aetiological basis for a complication diagnosis.

Requirement Reference

LRA DS expert group 2011 - useful for providing additional clinical detail for a comprehensive diagnosis list.

Proposed Data Values

Values as for diagnosis or for Procedure Description, linked to (as the aetiological basis for) a complication diagnosis.

Data Use

Information for patient and decision support.

Data Source

Copied from previous record entry.

Available Data Standards

SNOMED CT.

Complication Aetiology Date

Business Definition

The date the complication aetiology diagnosis was made or the date the complication aetiology procedure was performed. NOTE: Associated with a complication aetiology diagnosis or procedure.

Requirement Reference

LRA DS expert group 2011 – part of a set of data related to complication aetiology.

Proposed Data Values

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

Data Use

Patient information and continuing care.

Data Source

Previous record 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.

Complication Aetiology Responsible Person

Business Definition

The name of the person responsible for making the complication’s aetiological diagnosis or performing the procedure.

Requirement Reference

LRA DS expert group 2011 – part of a set of data related to complication aetiology.

Proposed Data Values

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

Data Use

Clinical context.

Data Source

Previous record entry.

Available Data Standards

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

Complication Aetiology Treatment Specialty

Business Definition

The treatment specialty of the person responsible for the complication aetiology diagnosis or procedure.

Requirement Reference

LRA DS expert group 2011 – part of a set of data related to complication aetiology.

Proposed Data Values

Codes for treatment specialty. Associated with a complication aetiology diagnosis or procedure.

Data Use

GPs / others contacts in follow-up activities.

Data Source

PAS.

Available Data Standards

European Commission medical specialties.

Complication Aetiology Date Of First Presentation

Business Definition

The date the complication aetiology diagnosis first presented. NOTE: Associated with a complication aetiology diagnosis.

Requirement Reference

LRA DS expert group 2011 – part of a set of data related to complication aetiology.

Proposed Data Values

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

Data Use

Patient information and continuing care.

Data Source

Previous record 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.

Date Of Presentation

Business Definition

The date of first presentation of physical signs and symptoms associated with the diagnosis, if known.

Requirement Reference

LRA DS expert group 2011 – clinically useful, particularly when there is a significant time gap between first presentation and diagnosis.

Proposed Data Values

A string with the format "YYYYMMDD".

Data Use

Patient and care provider information, clinical research.

Data Source

Copied from previous record 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.