Requirements Specification for Clinical Narrative
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| Opportunity to describe any additional significant information in narrative form.
Could include, for example, exceptional circumstances related to lack of consent to treatment, etc.
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).
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Clinical Narrative
Business DefinitionVery brief narrative description of the in-patient episode. Should include complications and nutritional status. (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).
Opportunity to describe any additional significant information in narrative form.
Could include, for example, exceptional circumstances related to lack of consent to treatment, etc.
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 ValuesFree text.
Data UsePatient information, continuing care.
Data SourceNew entry.
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