This release includes complete requirements specifications for Discharge Summary data content to support clinical and patient communication.

 

This release also includes proposed technical models for the following (subset of) Discharge Summary content areas:

• Demographics (GP details, Patient details)
• Admission details
• Discharge details
• Diagnoses at discharge
• Operations and procedures
• Reason for admission and presenting complaints
• Allergies
• Risks and warnings
• Clinical narrative / other significant information
• Current and stopped medications
• Advice, recommendations and future plans
• Information given to the patient and/or authorised representative
• Person(s) completing summary
• Distribution list

 

Copyright notice - This material is Crown Copyright. Included SNOMED CT content references are reproduced within the terms of the UK's Affiliate licence agreement with the International Health Terminology Standards Development Organisation (IHTSDO).

 

This Crown data and any related Crown products are licensed under the UK Open Government Licensing (OGL) Framework and by accepting this agreement, you are confirming you agree with the OGL in their use.

 

The license is available from the National Archives, and can be viewed at their website: http://www.nationalarchives.gov.uk/doc/open-government-licence/. Please be considerate of the following when using any of the data and products:

• If you are not accessing this material via TRUD (Technology Reference Data Update Distribution Service), you will need to register (for free) on this site (link as above) if you want to use the content
• You are free to use this data and products
• You should inform us immediately should you find any errors in the data or products so we can rectify such issues as quickly as possible
• We recommend that you keep a log of how and where you use the data and products to better prepare you, as and when new or updated data and products are published