Logical Record Architecture for Health and Social Care

Discharge Summary Release 0.02
Contents

Requirements Specification for Person Authoring Data

Details of the healthcare professional(s) authoring the summary. [Adapted 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)]. Includes ‘the name and position of the person to whom questions about the content of the Discharge Summary may be addressed, and complete and accurate contact details (including a telephone number) for that person. [2011/12 Standard Terms and Conditions for Acute Hospital Services (Department of Health, April 2011)]. Includes ‘contact details for the Provider’s facility’. [2011/12 Standard Terms and Conditions for Acute Hospital Services (Department of Health, April 2011)].

Person Authoring Data Name

Business Definition

Name of the person who takes overall responsibility for the complete discharge summary data.

Requirement Reference

- LRA DS expert group 2011 – for data provenance. - Keeping patients safe when they transfer between care providers – getting the medicines right, Part 1: Good practice guidance for health professions, Royal Pharmaceutical Society (Final Draft 06/06/2011).

Proposed Data Values

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

Data Use

Data provenance (used locally only).

Data Source

EHR system user identification.

Available Data Standards

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

Person Authoring Data Grade

Business Definition

Grade of the person who authored the data.

Requirement Reference

- LRA DS expert group 2011 – for data provenance. - Equivalent to ‘job title’ in Keeping patients safe when they transfer between care providers – getting the medicines right, Part 1: Good practice guidance for health professions, Royal Pharmaceutical Society (Final Draft 06/06/2011).

Proposed Data Values

Grade of person authoring data.

Data Use

Follow up care / contact.

Data Source

System sign on, manual entry by exception.

Available Data Standards

As per the Job Roles National Workforce Dataset v2.2.

Person Authoring Data Specialty

Business Definition

Speciality of the person who authors the discharge summary data.

Requirement Reference

LRA DS expert group 2011 – for data provenance.

Proposed Data Values

Speciality of person authoring data.

Data Use

Follow up care.

Data Source

System sign on, manual entry by exception.

Available Data Standards

Specialty of a Consultant as per the National Workforce Dataset (NWD) v2.2.

Person Authoring Data Treatment Speciality

Business Definition

Treatment Speciality is based on specialty, but also includes approved sub-specialties and treatment specialties used by lead care professionals including hospital consultants.

Requirement Reference

LRA DS expert group 2011 – for data provenance.

Proposed Data Values

Treatment Speciality of person authoring data.

Data Use

Follow up care.

Data Source

PAS.

Available Data Standards

NHS Data Model & Dictionary Version 3 Treatment Function Code.

Contact Telephone Numbers

Business Definition

Telephone number(s) associated with the person authoring the Discharge Summary.

Requirement Reference

Keeping patients safe when they transfer between care providers – getting the medicines right, Part 1: Good practice guidance for health professions, Royal Pharmaceutical Society (Final Draft 06/06/2011).

Proposed Data Values

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.

Discharge Summary Authoring Date

Business Definition

Date and time the discharge summary data was authored.

Requirement Reference

- LRA DS expert group 2011 – for data provenance. - Keeping patients safe when they transfer between care providers – getting the medicines right, Part 1: Good practice guidance for health professions, Royal Pharmaceutical Society (Final Draft 06/06/2011).

Proposed Data Values

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

Data Use

Policy requirements.

Data Source

System generated time and date stamp for ‘last modified on’, manual entry by exception.

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.