Logical Record Architecture for Health and Social Care

Discharge Summary Release 0.02

Requirements Specification for Distribution Record

A record of what was sent within the Discharge Summary, when and by whom. This is separate from the Distribution List. The Distribution Record is recorded in the EHR after the Summary is finished signed off and sent to its intended recipients. The person involved in sending could be an entirely new person who didn’t have a role in authoring the Discharge Summary. Requirement Reference: LRA DS expert group 2011.

Distribution Recipient Name

Business Definition

The name of a person who is intended to receive a copy of the Discharge Summary, to store as confidentiality information alongside the Discharge Summary in the originating system (not to be communicated to other information systems with a copy of the Discharge Summary).

Requirement Reference

LRA DS expert group 2011 – for information governance.

Proposed Data Values

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

Data Use

Information governance (local audit).

Data Source

New entry.

Distribution Recipient Organisation Name

Business Definition

The name of the organisation associated with the Recipient, to store as confidentiality information alongside the Discharge Summary in the originating system (not to be communicated to other information systems with a copy of the Discharge Summary).

Requirement Reference

LRA DS expert group 2011 – for information governance.

Proposed Data Values

Organisation name associated with coded identifier.

Data Use

Information governance (local audit).

Data Source

PAS or new entry.

Available Data Standards

Organisational code used within the NHS England and Wales and provided and maintained by SDS.

Description Of Distributed Content

Business Definition

A description of the content to distributed within the Discharge Summary, to store as confidentiality information alongside the Discharge Summary in the originating system (not to be communicated to other information systems with a copy of the Discharge Summary). Note: Includes version reference.

Requirement Reference

LRA DS expert group 2011 – for information governance.

Proposed Data Values

Free text.

Data Use

Information governance (local audit).

Data Source

New entry.

Person Responsible For Distribution Name

Business Definition

Name of the user who distributes the Discharge Summary, to store as confidentiality information alongside the Discharge Summary in the originating system (not to be communicated to other information systems with a copy of the Discharge Summary).

Requirement Reference

LRA DS expert group 2011 – for information governance.

Proposed Data Values

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

Data Use

Information governance (local audit).

Data Source

System sign-on or new entry.

Available Data Standards

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

Person Responsible For Distribution Role

Business Definition

Role of the user who distributes the Discharge Summary, to store as confidentiality information alongside the Discharge Summary in the originating system (not to be communicated to other information systems with a copy of the Discharge Summary).

Requirement Reference

LRA DS expert group 2011 – for information governance.

Proposed Data Values

Job roles codes.

Data Use

Information governance (local audit).

Data Source

System sign-on or new entry.

Available Data Standards

Job Roles National Workforce Dataset v2.2.

Distribution Date

Business Definition

Date and Time the Discharge Summary was sent to the intended recipients, to store as confidentiality information alongside the Discharge Summary in the originating system (not to be communicated to other information systems with a copy of the Discharge Summary).

Requirement Reference

LRA DS expert group 2011 – for information governance.

Proposed Data Values

A string with the format "YYYYMMDD".

Data Use

Information governance (local audit).

Data Source

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.