Logical Record Architecture for Health and Social Care

Discharge Summary Release 0.02
Contents

Requirements Specification for Significant Investigations And Results

The relevant investigations performed and their respective results, where present, e.g. endoscopy, CT Scan etc. It is important to highlight investigations and test results which relate to a GP action. (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)) Investigations are procedures that are undertaken to find out more information about a patient’s state of health or wellbeing. [NPFIT-NCR-DES-0135.07 NHS Care Record Elements].

Investigating Department

Business Definition

The clinical department responsible for the investigation.

Requirement Reference

Suggested by a member of the NHS CFH Pathology Programme team, accepted by the LRA Discharge Summary expert group 2011.

Proposed Data Values

A subset of the list of Specialty codes defined by the National Workforce Data set (NWD) v2.2 approved by the NHS Information Centre.

Data Use

Patient information, continuing care.

Data Source

Copied from previous record or new entry.

Investigation Performed

Business Definition

A description of the investigation performed. Investigations are ‘a range of tests, measurements and procedures to obtain further information about an individual’s status’ (from Headings for Communicating Clinical Information from the Personal Health Record: A Position Paper, Crown Copyright June 1998). The level of detail included in the description is at the author’s discretion. It has been suggested (in order to support brevity in the Discharge Summary) that it may be preferable to include only those results with an associated clinical interpretation recorded.

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

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 and continuing care.

Data Source

Copied from previous record entry.

Data Examples

- abdominal ultrasound - full blood count - mini mental state examination - ECT - gastroscopy - Waterlow Pressure Score

Available Data Standards

For laboratory investigations, NHS National Laboratory Medicine Catalogue (NLMC) Test Request Name or Test Request Display Name (associated with appropriate SNOMED CT concepts), LOINC or NPU. SNOMED CT concept expression for non-laboratory investigations (including the UK National Interim Clinical Imaging Procedure (NICIP) code set).

Clinical Interpretation Of Result

Business Definition

The clinical interpretation of the investigation result.

Requirement Reference

LRA DS expert group 2011 - useful to know for patient information and to support ongoing care.

Proposed Data Values

Coded expression or free text by exception.

Data Use

Patient information, continuing care.

Data Source

Copied from previous record entry.

Data Examples

- Atrial fibrillation with some lateral ischaemia - High red blood cell count

Available Data Standards

SNOMED CT.

Indication For Investigation

Business Definition

The primary reason for carrying out the investigation.

Requirement Reference

LRA DS expert group 2011 – useful to know, for patient information and for ongoing care.

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 Source

Copied from previous record entry.

Data Examples

- Suspected pneumonia - Family history of cancer of the colon

Available Data Standards

SNOMED CT.

Date Investigation Performed

Business Definition

The start date and optionally time when the investigation was performed.

Requirement Reference

LRA DS expert group 2011 – useful to know, for patient information and for ongoing care.

Proposed Data Values

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

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, NHS ISB 1501: Common User Interface - Time Display.

Time Investigation Result Available

Business Definition

The date and (optionally) time the investigation result was available in the EHR.

Requirement Reference

LRA DS expert group 2011 – useful to know locally and potentially for care follow-up reference.

Proposed Data Values

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

Data Use

Clinical audit or follow-up reference.

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, NHS ISB 1501: Common User Interface - Time Display.

Investigation Status

Business Definition

The activity status of the investigation.

Requirement Reference

LRA DS expert group 2011 – useful to know, for patient information and for ongoing care.

Proposed Data Values

* Post-starting action status (at discharge) * Suspended * Completed * Discontinued (Stopped before completion) * Cancelled (Stopped before completion) [adapted from Context values for actions_EDC_19032009.doc].

Data Use

Patient information, continuing care.

Data Source

Copied from previous record entry.

Available Data Standards

SNOMED CT.

Investigation Result

Business Definition

The result value, with unit of observation where applicable.

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

Different types of values and units may be associated with different types of investigation.

Data Use

Patient information, continuing care.

Data Source

Copied from previous record entry.

Available Data Standards

NHS National Laboratory Medicine Catalogue, LOINC, NPU and/or SNOMED CT.

Reference Range

Business Definition

The reference range applicable to the result, with unit of observation (where applicable).

Requirement Reference

LRA DS expert group 2011 - useful to know to understand the basis for the clinical interpretation of the result.

Proposed Data Values

Different types of values and units may be associated with different types of investigation.

Data Use

Patient information, continuing care.

Data Source

Copied from previous record entry (e.g. investigation result record).

Available Data Standards

Some guidance may be found in the NHS National Laboratory Medicine Catalogue.

Locating More Result Detail

Business Definition

Optional information to guide the reader to more results detail. Depending on the technical environment, this could be a hyperlink to the original results record, etc.

Requirement Reference

LRA DS expert group 2011 – useful to know, for patient information and for ongoing care.

Proposed Data Values

Free text.

Data Use

Follow-up care.

Data Source

Copied from previous record entry.

Link To GP Action

Business Definition

Indicator that this investigations' result is linked to a GP action described in the Advice, recommendations and plan to GP section of the Discharge Summary.

Requirement Reference

LRA DS expert group 2011 – useful to know, for patient information and for ongoing care.

Proposed Data Values

Yes / No.

Data Use

Relates this data to other data in the same document.

Data Source

New record entry.