Requirements Specification for Information Given To Patient And Or Authorised Representative
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| The verbal or written information or advice given to the patient and/or authorised representative such as relatives and carers.
Differentiation is required between information given to patients, carers and any other authorised representatives. [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 ‘any other relevant or necessary information (for the Patient)’. [2011/12 Standard Terms and Conditions for Acute
Hospital Services (Department of Health, April 2011)].
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Recipient Name
Business DefinitionThe name of the person who received verbal or written information or advice.
Requirement Reference LRA DS expert group 2011 – useful to support information governance.
Proposed Data Values[Prefixes][Given names][Family names][Suffixes].
Data UseInformation for patient and continuing care.
Data SourcePAS.
Available Data StandardsISO 21090 Health informatics data types, HL7 V3 Data Types, NHS MIM data types.
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Relationship To Patient
Business DefinitionThe relationship of the Recipient to the patient.
Requirement Reference LRA DS expert group 2011 – useful to support information governance.
Proposed Data Values
- Self
- Carer
- Spouse or civil partner
- Parent or Guardian
- Son or daughter
- Sibling
- Grandparent
- Grandchild
- Uncle or aunt
- Nephew or Niece
- Power of Attorney
- Proxy; Contact
- Proxy; Communication
- Proxy; Contact and Communication
- GP
- Other health service provider
- Social care service provider
Data UsePatient information governance.
Data SourceNew entry.
Available Data StandardsA potential extension of NHS Data Model & Dictionary Version 3.
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Verbal Communication Given
Business DefinitionA description of information communicated verbally.
Requirement Reference LRA DS expert group 2011 – useful to patient and for follow-up care.
Proposed Data ValuesFree text.
Data UseFollow-up care.
Data SourceNew entry.
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Written Communication Given
Business DefinitionA description of written communication provided.
NOTE: The written information including leaflets should include local as well as national information.
NOTE: All information given to patients/carers should be given in a simple understandable format without the use of acronyms
and clinical jargon.
Requirement Reference LRA DS expert group 2011 – useful to patient and for follow-up care.
Proposed Data ValuesFree text.
Data UseFollow-up care.
Data SourceNew entry.
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