Logical Record Architecture for Health and Social Care

Discharge Summary Release 0.02
Contents

Requirements Specification for Results Awaited

Brief description of the results awaited e.g. pathology, investigations, imaging. 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).

Investigation Name

Business Definition

The name of the investigation. NOTE: The Investigation expression could include the site and laterality where the investigation was performed.

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

Coded expression. 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.

Available Data Standards

SNOMED CT.

Investigation Request Date

Business Definition

Date the investigation was requested.

Requirement Reference

LRA DS expert group 2011 – useful to patient and for follow-up care.

Proposed Data Values

A string with the format "YYYYMMDD".

Data Use

Patient information, continuing care.

Data Source

Copied from previous record.

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.

Investigation Date Result Expected

Business Definition

Date of expected result, if known.

Requirement Reference

LRA DS expert group 2011 – useful to patient and for follow-up care.

Proposed Data Values

A string with the format "YYYYMMDD".

Data Use

Patient information, continuing care.

Data Source

Copied from previous record or new entry.

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.

Comments On Results Awaited

Business Definition

Opportunity to record any advice or instructions related to pending results.

Requirement Reference

LRA DS expert group 2011 – potentially useful to patient and for follow-up care.

Proposed Data Values

Free text.

Data Use

Patient information and continuing care.

Data Source

Copied from previous record entry.