Logical Record Architecture for Health and Social Care

Discharge Summary Release 0.02
Contents

Requirements Specification for Current Medications

A list of all prescribed or non-prescribed (e.g. over-the-counter) medications at time of discharge, including pre-admission medications that have changed or are continuing without change. This list is required for the following reasons: 1. To provide a complete list of the patient's current medications. 2. To ensure that GPs can check that the hospital was aware of all the patient's continuing medication. 3. To support the proper operation of prescribing interaction alerts / to avoid medication interactions with known negative effects. Not to include medications given temporarily during admission and stopped prior to discharge. Includes (but expands beyond) ‘details of any medication prescribed at the time of the Patient’s discharge’ [2011/12 Standard Terms and Conditions for Acute Hospital Services (Department of Health, April 2011)]. Includes (but expands beyond) ‘medication dispensed on discharge, medication prescribed and not dispensed (e.g. patient’s own), medications to be commenced after discharge and medication compliance aids (e.g. NOMAD / pill dispenser) being used’. [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)].

Reconciliation Status

Business Definition

Indication as to whether a pre-admission medication is continued or changed during the admission or whether a medication has been newly prescribed during the admission. A change could include a temporary suspension of a medication.

Requirement Reference

Medicines adherence: involving patients in decision about prescribed medicines and supporting adherence – NICE clinical guideline 76 (National Institute for Health and Clinical Excellence, January 2009).

Proposed Data Values

- Continued (unchanged from pre-admission) - Changed – Prescribed, not dispensed - Changed – Dispensed - New – Prescribed, not dispensed - New – Dispensed

Data Use

Provides visual indication to Discharge Summary readers on the reconciliation status at discharge of current medications.

Data Source

Copied from previous record entry or manual entry.

Current Medication Description

Business Definition

A prescribed or non-prescribed (e.g. ‘over the counter’) medication either with no stop date indicated or with a stop date that occurs after the date of discharge. Includes medications suspended temporarily during the hospital stay (and not yet re-started at discharge), indicated as a changed medication. Should include name, dose form, strength and unit dose of the medication taken by the patient, where applicable.

Requirement Reference

- Medicines Reconciliation: A Guide to Implementation (National Prescribing Centre, 2008). - Medicines adherence: Involving patients in decisions about prescribed medicines and supporting adherence – NICE clinical guideline 76 (National Institute for Health and Clinical Excellence, January 2009). - Name, Form, and Dose Strength in Keeping patients safe when they transfer between care providers – getting the medicines right, Part 1: Good practice guidance for health professions, Royal Pharmaceutical Society (Final Draft 06/06/2011).

Proposed Data Values

Medication name, dose form, monitored dosage system.

Data Use

Patient information, continuing care.

Data Source

Copied from previous record entry.

Available Data Standards

NHS dm+d.

Medication Dose Quantity

Business Definition

A specified quantity of a therapeutic agent, such as a drug, prescribed to be taken at one time or at stated intervals (from the NHS e-Prescription Service). Includes both value and unit of measure.

Requirement Reference

Medicines Reconciliation: A Guide to Implementation (National Prescribing Centre, 2008).

Proposed Data Values

Values and units.

Data Use

Patient information, continuing care.

Data Source

Copied from previous record.

Available Data Standards

NHS dm+d for units.

Medication Administration Description

Business Definition

How the medication was administered so as to get into the body or into contact with the body and constitutes part of the “where” (the other part being site). It is the “way in” or the course the medication must take to get to its destination. May include method of administration (e.g. by infusion, via nebuliser, via NG tube) and/or site of use (e.g. ‘to wound’, to left eye, etc.). The level of detail described is at the author’s discretion.

Requirement Reference

- Medicines Reconciliation: A Guide to Implementation (National Prescribing Centre, 2008). - Keeping patients safe when they transfer between care providers – getting the medicines right, Part 1: Good practice guidance for health professions, Royal Pharmaceutical Society (Final Draft 06/06/2011).

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

Patient information, continuing care.

Data Source

Copied from previous record.

Available Data Standards

NHS dm+d for route and site. SNOMED CT for Method.

Medication Dose Frequency

Business Definition

The number of occurrences of a periodic or recurrent process per unit time [ePS].

Requirement Reference

- Medicines Reconciliation: A Guide to Implementation (National Prescribing Centre, 2008). - Keeping patients safe when they transfer between care providers – getting the medicines right, Part 1: Good practice guidance for health professions, Royal Pharmaceutical Society (Final Draft 06/06/2011).

Proposed Data Values

Frequency at which the medication will be taken.

Data Use

Patient information, continuing care.

Data Source

Copied from previous record.

Available Data Standards

ISO health data types standard for frequency.

Medication Start Date

Business Definition

Date the medication at this dose was first taken by the patient. This data should be recorded to the best precision known, but may be imprecise (e.g. year only or month and year only). This is not intended as the date when a medication was first recorded within the health record or became known to a health service provider. Note: Any change in dose for the same medication would require a new start date. A change in route for the same medication at the same dose would not require a new start date.

Requirement Reference

- LRA DS expert group 2011 – useful to know for continuing care. - Requirement specified for Changed Medications in Keeping patients safe when they transfer between care providers – getting the medicines right, Part 1: Good practice guidance for health professions, Royal Pharmaceutical Society (Final Draft 06/06/2011).

Proposed Data Values

A string with the format "YYYYMMDD".

Data Use

Patient information, continuing care.

Data Source

Copied from previous record entry or new 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.

Medication End Date

Business Definition

Date for discontinuing the medication.

Requirement Reference

- Medicines Reconciliation: A Guide to Implementation (National Prescribing Centre, 2008). - Medicines adherence: Involving patients in decisions about prescribed medicines and supporting adherence – NICE clinical guideline 76 (National Institute for Health and Clinical Excellence, January 2009).

Proposed Data Values

A string with the format "YYYYMMDD".

Data Use

Patient information, continuing care.

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.

Medication Review Date

Business Definition

Date for reviewing whether the medication should be continued or changed.

Requirement Reference

- Medicines Reconciliation: A Guide to Implementation (National Prescribing Centre, 2008). - Medicines adherence: Involving patients in decisions about prescribed medicines and supporting adherence – NICE clinical guideline 76 (National Institute for Health and Clinical Excellence, January 2009).

Proposed Data Values

A string with the format "YYYYMMDD".

Data Use

Patient information, continuing care.

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.

Medication Review Responsibility

Business Definition

The person or organisation responsible for reviewing the medication.

Requirement Reference

Input received during the open review of draft LRA Discharge Summary technical models (2011).

Proposed Data Values

Free text.

Data Use

Patient information and continuing care.

Data Source

Copied from hospital medication record.

Data Examples

- GP - Specific GP Practice - This hospital - Specific nursing home - ‘Homecare’ service

Medication Quantity Dispensed

Business Definition

The quantity of medication dispensed.

Requirement Reference

LRA DS expert group 2011 – useful to know for continuing care.

Proposed Data Values

Real number (or further constrained) value with units.

Data Use

Patient information and continuing care.

Data Source

Copied from hospital medication record.

Data Examples

- 30 tablets.

Available Data Standards

UK dm+d.

Indication For Medication

Business Definition

The clinical reason for providing the medication. More than one reason may be appropriate for providing a medication.

Requirement Reference

- Medicines adherence: Involving patients in decisions about prescribed medicines and supporting adherence – NICE clinical guideline 76 (National Institute for Health and Clinical Excellence, January 2009). - Keeping patients safe when they transfer between care providers – getting the medicines right, Part 1: Good practice guidance for health professions, Royal Pharmaceutical Society (Final Draft 06/06/2011).

Proposed Data Values

Coded expressions. 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 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

Linked / copied from Diagnoses at Discharge, Allergy and Adverse Reactions, Operations and Procedures and Problems.

Data Examples

- Acute myocardial infarction, first, confirmed present. - Carcinoma of hepatic flexure, probably present, first episode.

Available Data Standards

SNOMED CT.

Medication Instructions

Business Definition

Guidance related to medication dose expressed in lay terms. Includes: - timing of the dosage (frequency and duration), - rate of administration, - “additional information” (e.g. swallow whole, on an empty stomach). May include details of variable dose regimens (e.g. oral corticosteroids, warfarin etc.). May include information about storage, unusual prescriptions, unusual supply issues or monitoring information.

Requirement Reference

Medicines Reconciliation: A Guide to Implementation (National Prescribing Centre, 2008).

Proposed Data Values

Free text. NOTE: Free text is also currently used in the NHS National Programme for IT’s electronic Prescriptions Service for dosage instructions. Future work to structure medications dose instructions for the NHS is intended, but not yet scheduled.

Data Use

Patient information and continuing care.

Data Source

Copied from hospital medication record.

Data Examples

- GP to initiate. - Patient to start in 3 days.

Available Data Standards

[Suggestion has been made to add a reference to a BMA Guideline for prescribing here].

Indication For Medication Change

Business Definition

The reason(s) for changing (between pre-admission and discharge) a current medication. This includes reasons for temporarily suspending a current medication.

Requirement Reference

- LRA DS expert group 2011 – useful to know for continuing care. - Keeping patients safe when they transfer between care providers – getting the medicines right, Part 1: Good practice guidance for health professions, Royal Pharmaceutical Society (Final Draft 06/06/2011).

Proposed Data Values

Free text.

Data Use

Patient information, continuing care.

Data Source

Manual entry or copied from a previous record (or linked with data elsewhere in this record).

Medication Change Description

Business Definition

Category of medication change between pre-admission and discharge. Includes changes in dose form, quantity, frequency or route. Includes temporary suspensions of a current medication to be recommenced following discharge (details for which should be included here).

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

Free text.

Data Use

Patient information, continuing care.

Data Source

Copied from previous record or new entry.

Date Of Latest Medication Change

Business Definition

The date of the latest change to this medication during this admission.

Requirement Reference

LRA DS expert group 2011 – useful to know for continuing care.

Proposed Data Values

A string with the format "YYYYMMDD".

Data Use

Patient information, continuing care.

Data Source

Manual 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.

Medication Compliance Aid

Business Definition

A device currently used by the patient to comply with their medication requirements. E.g. pill dispensers, medication reminder electronic devices etc.

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).

Proposed Data Values

Coded expression for medication device. 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

Patient information and continuing care.

Data Source

Copied from previous record entry.

Data Examples

- Pill dispenser. - Electronic medication reminders

Available Data Standards

SNOMED CT.

Medication Compliance Aid Comment

Business Definition

Additional information about a medication compliance aid. Could include information about how often it should be filled (e.g. weekly, monthly, etc.) and who is responsible for filling, etc.

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).

Proposed Data Values

Free text.

Data Use

Patient information and continuing care.

Data Source

Copied from previous record entry or new entry.

Data Examples

- To be filled monthly by patient’s local pharmacy.