Logical Record Architecture for Health and Social Care

Discharge Summary Release 0.02
Contents

Requirements Specification for Measures Of Physical Ability And Cognitive Function

Activity of Daily Living and cognitive scale scores if not independent, function weight/nutritional status at discharge. Requirement Reference: 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).

Measures Of Physical Ability

Business Definition

An assessment using a preferred assessment scale or clinical description to indicate the measure of physical ability of the patient at the time of discharge.

Requirement Reference

LRA DS expert group 2011 – potentially useful for patient information and for ongoing care.

Proposed Data Values

Coded expression with numerical result value, if appropriate. 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

Patient information and continuing care.

Data Source

Copied from previous record entry.

Data Examples

- Activity of Daily Living (with score).

Available Data Standards

SNOMED CT.

Cognitive Function

Business Definition

An assessment of the cognitive function of the patient at the time of discharge which may be determined using suitable cognitive and behaviour assessment techniques or clinical descriptions.

Requirement Reference

LRA DS expert group 2011 – potentially useful for patient information and for ongoing care.

Proposed Data Values

Coded expression with numerical result value, if appropriate. 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

Patient information, continuing care.

Data Source

Copied from previous record entry.

Data Examples

- Cognitive function scale (with score).

Available Data Standards

SNOMED CT.