Logical Record Architecture for Health and Social Care

Discharge Summary Release 0.02
Contents

Requirements Specification for Admission Details

Details of the patient's admission. 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).

Method Of Admission

Business Definition

How the patient was admitted to hospital e.g. Emergency, Elective, Transfer, Maternity.

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

- Elective Admission, when the DECISION TO ADMIT could be separated in time from the actual admission: • Waiting list • Booked • Planned - Emergency Admission, when admission is unpredictable and at short notice because of clinical need: • Accident and emergency or dental casualty department of the Health Care Provider • GENERAL PRACTITIONER: after a request for immediate admission has been made direct to a Hospital Provider, i.e. not through a Bed bureau, by a GENERAL PRACTITIONER or deputy • Bed bureau • Consultant Clinic, of this or another Health Care Provider • Admission via Mental Health Crisis Resolution Team * • Other means, examples are: - admitted from the Accident and Emergency Department of another provider where they had not been admitted - transfer of an admitted PATIENT from another Hospital Provider in an emergency - baby born at home as intended - Maternity Admission, of a pregnant or recently pregnant woman to a maternity ward (including delivery facilities) except when the intention is to terminate the pregnancy • Admitted ante-partum • Admitted post-partum - Other Admission not specified above • The birth of a baby in this Health Care Provider • Baby born outside the Health Care Provider except when born at home as intended. • Transfer of any admitted PATIENT from other Hospital Provider other than in an emergency NOTE: Some of these admission types may be out of scope for this LRA Discharge Summary work package.

Data Use

Central returns, research and audit, GP & other specialities info.

Data Source

PAS (including A&E PAS).

Available Data Standards

NHS Data Model & Dictionary Version 3 - Admission Method.

Source Of Admission

Business Definition

Where the patient was resident immediately prior to admission e.g. usual place of residence, temporary place of residence, penal establishment. NOTE: This data may be available outside the Discharge Summary and questions have been raised about its accuracy / reliability.

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

- Usual place of residence unless listed below, for example, a private dwelling whether owner occupied or owned by local authority, housing association or other landlord. This includes wardened accommodation but not residential accommodation where health care is provided. It also includes patients with no fixed abode. - Temporary place of residence when usually resident elsewhere (e.g. hotels, residential educational establishments) - Penal establishment, Court, or police station - NHS other hospital provider - high security psychiatric accommodation in an NHS hospital provider (NHS trust) - NHS other hospital provider - ward for general patients or the younger physically disabled or A & E department - NHS other hospital provider - ward for maternity patients or neonates - NHS other hospital provider - ward for patients who are mentally ill or have learning disabilities - NHS run care home - Local Authority residential accommodation i.e. where care is provided - Local Authority foster care - Babies born in or on the way to hospital - Non-NHS (other than Local Authority) run care home - Non NHS run hospital - Non-NHS (other than Local Authority) run Hospice

Data Use

Research and audit, central returns, info for GP & other specialities.

Data Source

PAS (including A&E PAS).

Available Data Standards

NHS Data Model & Dictionary Version 3.

Hospital Site Name

Business Definition

Name of physical provider site to which the patient was admitted.

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

Code with associated name or free text as exception. NOTE: User interfaces could display just the organisation name associated with the code, rather than the code itself.

Data Use

Research and audit, central returns.

Data Source

PAS.

Available Data Standards

NHS Data Model & Dictionary Version 3 - Organisation Code.

Responsible Trust

Business Definition

The NHS hospital trust responsible for admitting the patient (this may not be the same as the name of the hospital).

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

Name of the responsible Trust.

Data Use

Commissioning.

Data Source

PAS.

Available Data Standards

NHS Data Model & Dictionary Version 3 - Organisation Code (Code Of Provider).

Date And Time Of Admission

Business Definition

The date and time the patient was admitted to hospital.

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). - Medicines Reconciliation: A Guide to Implementation (National Prescribing Centre, 2008). - Date requirement only from 2011/12 Standard Terms and Conditions for Acute Hospital Services (Department of Health, April 2011).

Proposed Data Values

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

Data Use

Audit, research, Commissioning (based on length of stay).

Data Source

PAS.

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.