# Logical Record Architecture for Health and Social Care
## Discharge Summary Release 0.02

Contents
# Requirements Specification for Other Significant Problems At Discharge
Opportunity to record other significant problems (issues requiring health service or carer attention) at discharge. Requirement Reference: LRA DS expert group 2011.
## Problem Description ### Business Definition Issue requiring health service or carer attention. ### Requirement Reference LRA DS expert group 2011 - Useful in maintaining and communicating problem lists and allows the ability to identify non-diagnosis issues relevant to ongoing care at time of discharge. ### 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 Information for patients and care providers, updates to the patient’s primary or shared care records, use in primary care decision support algorithms. ### Data Source Copied from previous record entry. ### Data Examples - risk for falls - chest pain on exertion - family history of early cardiac death - planned hysterectomy - failure to take medications as prescribed - status post Coronary Artery Bypass Graft - lives alone without social support ### Available Data Standards SNOMED CT.
## Date Problem Recorded ### Business Definition The date and time when the problem was recorded. ### Requirement Reference LRA DS expert group 2011 – useful to know for follow-up care. ### Proposed Data Values A string with the format "YYYYMMDDHHMMSS.UUUU[+|-ZZzz]". ### Data Use Patient and care provider information. ### 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.
## Responsible Person ### Business Definition Person responsible for recording the problem. ### Requirement Reference LRA DS expert group 2011 – useful for clinical context or follow-up. ### Proposed Data Values [Prefixes][Given names][Family names][Suffixes]. ### Data Use Follow-up contact. ### Data Source PAS. ### Available Data Standards ISO 21090 Health informatics data types, HL7 V3 Data Types, NHS MIM data types.
## Responsible Consultant Treatment Specialty ### Business Definition Treatment Speciality is based on specialty, but also includes approved sub-specialties and treatment specialties used by hospital consultants. ### Requirement Reference LRA DS expert group 2011 – useful as clinical context. ### Proposed Data Values Treatment Speciality code. ### Data Use Provides clinical context. ### Data Source PAS. ### Available Data Standards NHS Hospital Episode Statistics ‘Treatment Specialty’.