Logical Record Architecture for Health and Social Care

Discharge Summary Release 0.02
Contents

Requirements Specification for Patient Details

Details of the person being discharged from hospital. Requirement References: - 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). - Requirement for ‘the Patient’s demographics’ in 2011/12 Standard Terms and Conditions for Acute Hospital Services (Department of Health, April 2011).

Patient Name

Business Definition

The name of the patient.

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). - Medicines Reconciliation: A Guide to Implementation (National Prescribing Centre, 2008). - 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

Identification.

Data Source

PAS.

Available Data Standards

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

Name Known As

Business Definition

An alias name of the patient by which he/she is commonly known.

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

Identification.

Data Source

PAS.

Available Data Standards

ISO 21090 Health informatics data types, NHS ISB 1506: Common User Interface - Patient Name Input and Display, NHS ISB 1505: Patient Banner.

Date Of Birth

Business Definition

The patient's Date of Birth.

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). - Medicines Reconciliation: A Guide to Implementation (National Prescribing Centre, 2008). - 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 "YYYYMMDD".

Data Use

Identification.

Data Source

PAS.

Available Data Standards

ISO 11404 - Point in Time, NHS ISB 1505: Patient Banner, NHS ISB 1503: Common User Interface - Date Display.

Gender

Business Definition

A coded representation of the current gender of the person. Gender is an individual’s self-declared (or inferred by observation for those unable to declare) perception of being male or female. Person gender is behavioural (i.e. how an individual wishes to be treated socially) and must not be confused with person sex which can determine how an individual will be treated clinically.

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

- Not known - Male - Female - Other specific; The person has a clear idea of what their gender is, but it is neither discretely male nor female, e.g. 'intersex', 'transgender', 'third gender'. - Not specified; The person is unable to specify their current gender or does not have a clear idea of what their current gender is.

Data Use

Identification and for addressing personal communications appropriately with the patient.

Data Source

PAS.

Available Data Standards

NHS ISB 1507: Common User Interface - Sex and Current Gender Input and Display, NHS ISB 1505: Common User Interface - Patient Banner.

NHS Number

Business Definition

The unique patient identifier provided by the NHS in England and Wales.

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). - Medicines Reconciliation: A Guide to Implementation (National Prescribing Centre, 2008). - 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

Patient's NHS number.

Data Use

Identification.

Data Source

PAS.

Available Data Standards

Government Data Standards Catalogue, NHS ISB 1504: Common User Interface - NHS Number Input and Display, NHS ISB 1505: Patient Banner.

Local Identifier

Business Definition

Used locally only, also useful when patient does not have a unique NHS Number (e.g. ‘dummy’ NHS Number for visitor).

Requirement Reference

LRA DS expert group 2011 – to assist in tracing patient identification in cases where ‘dummy’ NHS numbers have been used.

Proposed Data Values

Local ID code.

Data Use

Identification.

Data Source

PAS.

Available Data Standards

NHS Data Model & Dictionary Version 3 - Local Patient Identifier.

Patient Address

Business Definition

A patient's usual address is the address at which (s)he currently lives and which the patient states is his usual address.

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). - 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 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 (unless different from discharge destination address).

Data Source

PAS.

Available Data Standards

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

Patient Telephone Numbers

Business Definition

Telephone number(s) associated with the patient.

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

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

PAS.

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.