Logical Record Architecture for Health and Social Care

Discharge Summary Release 0.02
Contents

Requirements Specification for Distribution List

The parties that will be provided copies of the discharge summary. [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)]. NOTE: there may be a link (managed mentally by the Discharge Summary author) between Living Alone information, and Patient's wishes, concerns, etc. re communications and the parties on this list. The LRA DS Expert Group 2011 noted that in principle, patient consent for all parties on the distribution list should be managed and also noted that this may be achieved in various ways operationally so as to be efficient within the care workflow.

Recipient Name

Business Definition

The name of a person who is intended to receive a copy of the Discharge Summary.

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

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

Data Use

Information governance.

Data Source

EHR system user identification.

Available Data Standards

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

Organisation Name

Business Definition

The name of the organisation associated with the Recipient.

Requirement Reference

LRA DS expert group 2011 – for information governance.

Proposed Data Values

Organisation name associated with coded identifier.

Data Use

Information governance.

Data Source

PAS or previous record entry.

Available Data Standards

This is the organisational code used within the NHS England and Wales and provided and maintained by SDS. This information is optional and needs to be completed only if the discharge summary is being sent to an organisation or department rather than an individual.

Recipient Address

Business Definition

The address of the Recipient.

Requirement Reference

LRA DS expert group 2011 – for information governance.

Proposed Data Values

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

Information governance.

Data Source

PAS.

Available Data Standards

BS7666 address standard.

Relationship To Patient

Business Definition

The relationship that the recipient of the information has with the patient. This may include the patient himself/herself or a person who represents the patient.

Requirement Reference

LRA DS expert group 2011 – for 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 - Other

Data Use

Information governance.

Data Source

Coded manual entry.

Available Data Standards

A potential extension of the NHS Data Model & Dictionary Version 3.