Logical Record Architecture for Health and Social Care

Discharge Summary Release 0.02
Contents

Requirements Specification for Stopped Medications

A list of medications that were discontinued during this admission. To include: - Pre-admission medications stopped during admission and still discontinued at time of discharge. - Medications started during this admission and stopped because of adverse reaction (this should also appear in the adverse reaction section of the Discharge Summary). - Medications stopped because of ineffectiveness. - Pre-admission medications stopped because of course conclusion (i.e. planned end date occurred during admission). Requirement Reference: LRA DS expert group 2011.

Stopped Medication

Business Definition

The name of the stopped medication. The medication will consist of the name and optionally the form, strength, and unit dose. To include: - Pre-admission medications stopped during admission and still discontinued at time of discharge. - Medications started during this admission and stopped because of adverse reaction (this should also appear in the adverse reaction section of the Discharge Summary). - Medications stopped because of ineffectiveness. - Pre-admission medications stopped because of course conclusion (i.e. planned end date occurred during admission).

Requirement Reference

- Medicines Reconciliation: A Guide to Implementation (National Prescribing Centre, 2008). - Medicines adherence: Involving patients in decisions about prescribed medicines and supporting adherence – NICE clinical guideline 76 (National Institute for Health and Clinical Excellence, January 2009).

Proposed Data Values

Name of stopped medication.

Data Use

Patient information, continuing care (e.g. to allow for automated prompts to update the Current Medications lists for this patient in the patient records of Discharge Summary recipients).

Data Source

Manual entry or copied from previous record entry.

Available Data Standards

UK dm+d.

Medication Start Date

Business Definition

Date the medication was first taken by the patient, if known (may be approximate).

Requirement Reference

LRA DS expert group 2011 – useful for reconciling current medications lists between care providers, and for patient / care provider information

Proposed Data Values

A string with the format "YYYYMMDD".

Data Use

Patient information, continuing care.

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.

Medication Stop Date

Business Definition

The date the medication was discontinued.

Requirement Reference

LRA DS expert group 2011 – useful for reconciling current medications lists between care providers, and for patient / care provider information.

Proposed Data Values

A string with the format "YYYYMMDD".

Data Use

Patient information, continuing care.

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.

Indication For Stopping Medication

Business Definition

Rationale for stopping the medication, current at the time of discharge.

Requirement Reference

- Medicines Reconciliation: A Guide to Implementation (National Prescribing Centre, 2008). - Medicines adherence: Involving patients in decisions about prescribed medicines and supporting adherence – NICE clinical guideline 76 (National Institute for Health and Clinical Excellence, January 2009).

Proposed Data Values

Coded expressions. 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

Information for patients and care providers.

Data Source

Linked / copied from Diagnoses at Discharge, Allergy and Adverse Reactions, Operations and Procedures and Problems.

Data Examples

- Achieved goal. - Lack of effect. - Patient declined. - No longer applicable (e.g. the patient was taking a pregnancy medication and is no longer pregnant). - Patient cannot swallow a particular tablet (this may also be entered as a Risk / Warning in the Discharge Summary). - Product discontinued (e.g. a new product has been launched to replace an older product).

Available Data Standards

SNOMED CT.

Indication For Medication Before Stopping

Business Definition

The reason the medication had been given (before being stopped).

Requirement Reference

LRA DS expert group 2011 – useful for reconciling current medications lists between care providers, and for patient / care provider information.

Proposed Data Values

Coded expressions. 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

Information for patients and care providers.

Data Source

Linked / copied from Diagnoses at Discharge, Allergy and Adverse Reactions, Operations and Procedures and Problems.

Data Examples

- Acute myocardial infarction, first, confirmed present. - Carcinoma of hepatic flexure, probably present, first episode.

Available Data Standards

SNOMED CT.