Logical Record Architecture for Health and Social Care

Discharge Summary Release 0.02
Contents

Requirements Specification for Person Entering Data

Details of the user entering the discharge summary data. Requirement Reference: LRA DS expert group 2011.

Person Entering Data Name

Business Definition

Name of the user entering the discharge summary data into the system.

Requirement Reference

LRA DS expert group 2011 – local audit purposes.

Proposed Data Values

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

Data Use

Local data provenance.

Data Source

EHR system user identification.

Available Data Standards

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

Person Entering Data Role

Business Definition

Grade of the user entering the discharge summary data into the system.

Requirement Reference

LRA DS expert group 2011 – local audit purposes.

Proposed Data Values

Role code.

Data Use

Local data provenance.

Data Source

System sign on.

Available Data Standards

Job Roles National Workforce Dataset v2.2.

Date Of Discharge Record Entry

Business Definition

Date of completion of discharge record.

Requirement Reference

LRA DS expert group 2011 – local audit purposes.

Proposed Data Values

A string with the format "YYYYMMDD".

Data Use

Local data provenance.

Data Source

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

Available Data Standards

ISO 11404 - Point in Time, NHS ISB 1503: Common User Interface - Date Display.

Document Version

Business Definition

Version of the discharge summary once the data has been entered. NOTE: If a discharge summary is being updated, then the document version number will be incremented.

Requirement Reference

LRA DS expert group – useful to track any updates made to the document.

Proposed Data Values

Undefined.

Data Use

Shared reference for data integrity.

Data Source

Data author.