Logical Record Architecture for Health and Social Care

Discharge Summary Release 0.02
Contents

Requirements Specification for Person Verifying Data

Details of the healthcare professional(s) verifying the summary. Requirement Reference: Adapted from 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).

Person Verifying Data Name

Business Definition

Name of the person who verifies the discharge summary data.

Requirement Reference

LRA DS expert group 2011 – for data provenance.

Proposed Data Values

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

Data Use

Data provenance (used locally only).

Data Source

EHR system user identification.

Available Data Standards

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

Person Verifying Data Grade

Business Definition

Grade of the person who verifies the discharge summary data.

Requirement Reference

LRA DS expert group 2011 – for data provenance.

Proposed Data Values

Grade of person verifying data.

Data Use

Follow up care.

Data Source

System sign on, manual entry by exception.

Available Data Standards

UK Job Roles National Workforce Dataset v2.2.

Person Verifying Data Specialty

Business Definition

Speciality of the person who verifies the discharge summary data.

Requirement Reference

LRA DS expert group 2011 – for data provenance.

Proposed Data Values

Speciality of person verifying data.

Data Use

Follow up care.

Data Source

System sign on, manual entry by exception.

Available Data Standards

Specialty of a Consultant as per the National Workforce Dataset (NWD) v2.2.

Person Verifying Data Treatment Speciality

Business Definition

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

Requirement Reference

LRA DS expert group 2011 – for data provenance.

Proposed Data Values

Treatment Speciality of person verifying data.

Data Use

Follow up care.

Data Source

PAS.

Available Data Standards

NHS Data Model & Dictionary Version 3 Treatment Function Code.

Discharge Summary Verification Date

Business Definition

Date the discharge summary data was verified.

Requirement Reference

LRA DS expert group 2011 – for data provenance.

Proposed Data Values

A string with the format "YYYYMMDD".

Data Use

Policy requirements.

Data Source

System generated date stamp for ‘last modified on’, manual entry by exception.

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.