Logical Record Architecture for Health and Social Care

Discharge Summary Release 0.02
Contents

Requirements Specification for Other Significant Problems At Discharge

Opportunity to record other significant problems (issues requiring health service or carer attention) at discharge. Requirement Reference: LRA DS expert group 2011.

Problem Description

Business Definition

Issue requiring health service or carer attention.

Requirement Reference

LRA DS expert group 2011 - Useful in maintaining and communicating problem lists and allows the ability to identify non-diagnosis issues relevant to ongoing care at time of discharge.

Proposed Data Values

Coded expression. 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).

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.

Data Source

Copied from previous record entry.

Data Examples

- risk for falls - chest pain on exertion - family history of early cardiac death - planned hysterectomy - failure to take medications as prescribed - status post Coronary Artery Bypass Graft - lives alone without social support

Available Data Standards

SNOMED CT.

Date Problem Recorded

Business Definition

The date and time when the problem was recorded.

Requirement Reference

LRA DS expert group 2011 – useful to know for follow-up care.

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 recording the problem.

Requirement Reference

LRA DS expert group 2011 – useful for clinical context or follow-up.

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 clinical context.

Proposed Data Values

Treatment Speciality code.

Data Use

Provides clinical context.

Data Source

PAS.

Available Data Standards

NHS Hospital Episode Statistics ‘Treatment Specialty’.