Logical Record Architecture for Health and Social Care

Discharge Summary Release 0.02
Contents

Requirements Specification for Reason For Admission And Presenting Complaints

The health problems and issues experienced by the patient resulting in their hospital admission, e.g. chest pain, blackout, fall, a specific procedure, investigation or treatment. Note: admission may be the result of a combination of factors. An issue may be either a presenting complaint or a reason for admission or both. 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).

Reason For Contact

Business Definition

A ‘stated reason from a health care professional, patient or organisation on the necessity of the patient professional encounter’ (from Headings for Communicating Clinical Information from the Personal Health Record: A Position Paper, Crown Copyright June 1998). A reason for admission is a particular type of reason for contact. The Discharge Summary may include multiple reasons for 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).

Proposed Data Values

Coded expression, which may include disease state, medical condition, responses and reactions to therapies (with anatomical site and laterality identified where appropriate). 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

Continuing care, clinical audit / research.

Data Source

Admission record.

Data Examples

- Colles fracture and lives alone without social support (reasons for admission) - Elective left hip replacement

Available Data Standards

SNOMED CT.

Presenting Complaint

Business Definition

An admission issue that represents a ‘patient want or requirement for help’ (adapted from ‘Needs’ in Headings for Communicating Clinical Information from the Personal Health Record: A Position Paper, Crown Copyright, June 1998). Multiple presenting complaints may be recorded.

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). - Adapted from ‘presenting condition’ in, Medicines Reconciliation: A Guide to Implementation (National Prescribing Centre, 2008).

Proposed Data Values

Coded expression, which may include disease state, medical condition, responses and reactions to therapies (with anatomical site and laterality identified where appropriate). 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

Continuing care, clinical audit / research.

Data Source

Admission record.

Data Examples

- Wrist pain – left - Chest pain - Blackout - Fall

Available Data Standards

SNOMED CT.

Issue Onset Date

Business Definition

If applicable, the date of onset of the perceived problem, reason for admission or presenting complaint.

Requirement Reference

LRA DS expert group 2011 – clinically useful to know, if available, how long the issue has been present.

Proposed Data Values

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

Data Use

Used in problem-oriented records for ongoing care.

Data Source

Admission record.

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.