Logical Record Architecture for Health and Social Care

Discharge Summary Release 0.02
Contents

Requirements Specification for Discharge Details

Details of the patient's discharge. 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).

Date And Time Of Discharge

Business Definition

A record of the date and time that the patient was discharged from hospital.

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). - Medicines Reconciliation: A Guide to Implementation (National Prescribing Centre, 2008). - Date requirement only from 2011/12 Standard Terms and Conditions for Acute Hospital Services (Department of Health, April 2011).

Proposed Data Values

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

Data Use

PAS.

Data Source

Audit, research, Commissioning (based on length of stay).

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.

Discharge Method

Business Definition

The mode of patient discharge from hospital.

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

- Patient discharged on clinical advice or with clinical consent - Patient discharged him/herself or was discharged by a relative or advocate - Patient died - Stillbirth - Patient discharged by mental health review tribunal, Home Secretary or court (remove for current RCP DS)

Data Use

Audits, Research, Central returns.

Data Source

PAS.

Available Data Standards

NHS Data Model & Dictionary Version 3 - Discharge Method.

Type Of Destination

Business Definition

Type of patient destination on discharge, can include private dwelling, penal establishment, care home etc (National Code).

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

- Usual place of residence unless listed below, for example, a private dwelling whether owner occupied or owned by local authority, housing association or other landlord. This includes wardened accommodation but not residential accommodation where health care is provided. It also includes patients with no fixed abode. - Temporary place of residence when usually resident elsewhere (includes hotel, residential educational establishment) - Repatriation from high security psychiatric accommodation in an NHS Hospital Provider (NHS Trust) - Court - Penal establishment or police station - High Security Psychiatric Hospital, Scotland - NHS other hospital provider; high security psychiatric accommodation - NHS other hospital provider; medium secure unit - NHS other hospital provider; ward for general patients or the younger physically disabled - NHS other hospital provider; ward for maternity patients or neonates - NHS other hospital provider; ward for patients who are mentally ill or have learning disabilities - NHS run Care Home - Local Authority residential accommodation i.e. where care is provided - Local Authority foster care - Not applicable; patient died or still birth - Non-NHS run hospital; medium secure unit - Non-NHS (other than Local Authority) run Care Home - Non-NHS run hospital - Non-NHS (other than Local Authority) run Hospice

Data Use

Central returns, Research, Audit and GP info.

Data Source

PAS.

Available Data Standards

NHS Data Model & Dictionary Version 3.

Destination Address

Business Definition

The address where the patient is being discharged. NOTE: Not required if patient’s own home. NOTE: Needs business process to validate currency before discharge.

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

Address Prefix, Building Name and Building Number; Dependent Street or Road Name, and Street or Road Name; Dependent Locality and Double dependent locality; Postal Town; Postal County; Postal Code; PAF Key - unique ID for an address allocated by the Royal Mail.

Data Use

Contact (unless patient's address).

Data Source

PAS.

Available Data Standards

BS7666 address standard, NHS ISB 1500: Common User Interface - Address Input and Display.

Living Alone

Business Definition

Indicator for whether the patient lives alone. NOTE: The LRA Discharge Summary expert group 2011 questioned how this would be consistently defined (i.e. what is the definition for ‘living alone’) and also who was expected to capture and use this data. (For example, if this was expected to have clinical significance, it was suggested that this data would more appropriately be included in the Clinical Narrative or Problems or Issues at Discharge, along with clinical context.) This requirement has been included in order to be consistent with the published Academy of Medical Royal Colleges Discharge Summary content standard, but clarification will be requested as input to future iterations of this professional standard.

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

Yes / No. [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)].

Data Use

Unknown.

Data Source

Unknown.

Discharge Destination Organisation

Business Definition

A code (with associated name) which identifies an organisation uniquely.

Requirement Reference

Adapted from ‘Discharge Destination’ in, 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

Organisation code (with associated name) or free text.

Data Use

GP and allied health for after care.

Data Source

PAS.

Available Data Standards

NHS Data Model & Dictionary Version 3 - Organisation Code.

Discharging Consultant Name

Business Definition

Name of the consultant responsible for the patient at time of discharge.

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 ‘Consultant’ in, Medicines Reconciliation: A Guide to Implementation (National Prescribing Centre, 2008). - 2011/12 Standard Terms and Conditions for Acute Hospital Services (Department of Health, April 2011).

Proposed Data Values

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

Data Use

Follow-up contact.

Data Source

PAS.

Available Data Standards

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

Discharging Consultant ID

Business Definition

Identifier of the consultant responsible for the patient at time of discharge.

Requirement Reference

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

Proposed Data Values

Consultant unique identifier.

Data Use

After care contact.

Data Source

PAS.

Available Data Standards

NHS Data Model & Dictionary Version 3 - Consultant Code.

Discharging Specialty Department

Business Definition

The name of the speciality/department responsible for the patient at the time of discharge.

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

Locally-defined Trust department name in free text.

Data Use

After care contact.

Data Source

PAS.