Logical Record Architecture for Health and Social Care

Discharge Summary Release 0.02
Contents

Requirements Specification for Community And Specialist Services Advice Recommendations And Future Plan

Actions requested/planned/agreed directly with community services (community matron, palliative care, specialist nurse practitioner, rehab team, social services and community service). Actions via the GP for these services would be recorded as advice to the GP. To include: - Action. - Person responsible. - Appropriate date and time. 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).

Community And Specialist Services Actions

Business Definition

Advice, recommendations or plan actions directed to community and specialty services.

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 Value

Free text.

Data Use

Patient information and continuing care.

Data Source

Copied from previous record or new entry.

Service Organisation Responsible For Action

Business Definition

The organisation responsible for taking a community or specialist service action. To be used only if the responsibility lies with an organisation rather than an individual.

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 Value

Organisation codes.

Data Use

Contact, information for patient and follow-up care.

Data Source

Copied from previous record or new entry.

Available Data Standards

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

Contact Person

Business Definition

Service person who may be contacted concerning this action.

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 Value

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

Data Use

Contact.

Data Source

Copied from previous record entry or new record entry.

Available Data Standards

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

Contact Address

Business Definition

The address of the service.

Requirement Reference

LRA DS expert group 2011 – useful for contact.

Proposed Data Value

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.

Data Source

Copied from previous record / PAS.

Available Data Standards

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

Contact Telephone Numbers

Business Definition

Telephone numbers associated with the service.

Requirement Reference

LRA DS expert group 2011 – useful for contact.

Proposed Data Value

Telephone number(s), with an optional 'Use' code or set of codes which may be assigned to differentiate number type : - home - primary home - vacation home - work place - direct (to the person) - public - temporary - answering service - emergency contact - mobile contact - pager (NOTE: more than one of the use descriptions above may apply to the same number).

Data Use

Contact.

Data Source

Previous record entry or new entry.

Available Data Standards

e-GIF GDSC standard for UK Telephone Number, ISB 1508: Common User Interface - Telephone Number Input and Display, Telecommunication Address Use codes from ISO 21090.

Date For Actions

Business Definition

The date(s) and optionally time when the action is planned to be executed.

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 Value

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

Data Use

Patient information, continuing care.

Data Source

Copied from previous record or 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, NHS ISB 1501: Common User Interface - Time Display.