Logical Record Architecture for Health and Social Care

Discharge Summary Release 0.02
Contents

Requirements Specification for Significant Treatments And Changes Made To Treatments

The relevant treatments which the patient received during the inpatient stay. Can include medication treatments given whilst an inpatient. [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: this is for non-procedural treatments. [LRA DS expert group 2011].

Treatment Description

Business Definition

Treatments are procedures that are intended to have a therapeutic, preventative, curative or palliative effect. [NPFIT-NCR-DES-0135.07 NHS Care Record Elements]. If a medication treatment, the description may include dose form.

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

SNOMED CT concept expressions for treatments. 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). If a medication treatment, the text string agreed as an unambiguous name for a concept in the UK dm+d (Drugs, Medicines and Devices terminology), according to the dm+d editorial policy [ePS].

Data Use

Patient information, continuing care.

Data Source

Copied from previous record entry.

Data Examples

- blood transfusion - chemotherapy

Available Data Standards

SNOMED CT.

Comments

Business Definition

General notes on the treatment administered to the patient during the inpatient stay.

Requirement Reference

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

Proposed Data Values

Free text.

Data Use

Patient information, continuing care.

Data Source

Copied from previous record entry.

Treatment Onset Time

Business Definition

Date and time treatment was begun.

Requirement Reference

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

Proposed Data Values

A string with the format "YYYYMMDDHHMMSS.UUUU[+|-ZZzz]".

Data Use

Patient information, continuing care.

Data Source

Copied from previous record 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, NHS ISB 1501: Common User Interface - Time Display.

Treatment End Time

Business Definition

Date and time treatment ended.

Requirement Reference

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

Proposed Data Values

A string with the format "YYYYMMDDHHMMSS.UUUU[+|-ZZzz]".

Data Use

Patient information, continuing care.

Data Source

Copied from previous record 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, NHS ISB 1501: Common User Interface - Time Display.

Medication Treatment Dose Quantity

Business Definition

A specified quantity of a therapeutic agent, such as a drug, prescribed to be taken at one time or at stated intervals [ePS]. Includes both value and unit of measure.

Requirement Reference

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

Proposed Data Values

Real number or may depend on the therapeutic agent with units.

Data Use

Patient information, continuing care.

Data Source

Copied from previous record entry.

Available Data Standards

UCUM for units.

Medication Treatment Dose Frequency

Business Definition

The number of occurrences of a periodic or recurrent process per unit time [ePS].

Requirement Reference

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

Proposed Data Values

Frequency at which the medication will be taken.

Data Use

Patient information, continuing care.

Data Source

Copied from previous record entry.

Available Data Standards

ISO health data types standard for frequency.

Medication Treatment Administration Description

Business Definition

How the medication was administered so as to get into the body or into contact with the body and constitutes part of the “where” (the other part being site). It is the “way in” or the course the medication must take to get to its destination. May include method of administration (e.g. by infusion, via nebuliser, via NG tube) and/or site of use (e.g. ‘to wound’, to left eye, etc.). The level of detail described is at the author’s discretion.

Requirement Reference

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

Proposed Data Values

Coded expression.

Data Use

Patient information, continuing care.

Data Source

Copied from previous record entry.

Available Data Standards

SNOMED CT.