# COMPOSITION: Discharge Summary

COMPOSITION: Discharge Summary

@session_time.high.value = Date of completion of discharge record

ENTRY: GenericAdmissionEvent
GENERAL_ACTIVITY_ELEMENT: GenericAdmissionEvent

@obs_time = Date of admission and Time of admission

@meaning = Admission Event meaning

- meaning.code.semantic - GUID for SCT expression

SCT expression:

243796009 | situation with explicit context | :
{ 363589002 | associated procedure | = ( 305056002 | admission procedure | :
~ 260870009 | priority |
= ( ( 103390000 | elective | )
OR ( 25876001 | emergency | )
)
)
, 408730004 | procedure context | = < 410523001 | post-starting action status |
, 408731000 | temporal context | = < 410510008 | temporal context value |
, 408732007 | subject relationship context | = < 125676002 | person |
}

<hasContext>

COMPONENT_RELATIONSHIP_TYPE.meaning.code.enum = hasContext

UNBOUND_DATA_ELEMENT: Admission Method

Specialises: ** To create Domain Model **

@value: CD.CV = Admission Method values

- value.code.enum =

Elective waiting list admission,

Elective booked admission,

Elective planned admission,

Emergency Accident and emergency or dental casualty department of the Health Care Provider,

Emergency admission after a request for immediate admission has been made direct to a Hospital Provider i.e. not through a Bed bureau by a GENERAL PRACTITIONER or deputy,

Emergency admission Consultant Clinic of this or another Health Care Provider,

Emergency admitted from the Accident And Emergency Department of another provider where they had not been admitted,

Emergency transfer of an admitted PATIENT from another Hospital Provider in an emergency,

Emergency baby born at home as intended,

Maternity admission admitted ante-partum,

Maternity admission admitted post-partum,

Birth of a baby in this Health Care Provider,

Baby born outside the Health Care Provider except when born at home as intended,

Transfer of any admitted patient from other Hospital Provider other than in an emergency

<location>

ENTRY.other_participants is of type PARTICIPATION

PARTICIPATION.type = LOC

<ORGANISATIONAL_ROLE>: IdentifiableOrganisationalRole

@id: II = Hospital Site id

<played by>
ORGANISATION_ENTITY: OrganisationEntity

@name = Hospital Site Name --unstructured

<is scoped by>

ROLE_RELATIONSHIP.type = is scoped by

<ORGANISATIONAL_ROLE>: IdentifiableOrganisationalRole

@id: II = Hospital Trust id

<played by>
ORGANISATION_ENTITY: OrganisationEntity
<source>

ENTRY.other_participants is of type PARTICIPATION

PARTICIPATION.type = ORG (origin) --Admission Source

FUNCTIONAL_ROLE_CHOICE: OtherParticipationsChoice
FUNCTIONAL_ROLE:OtherFunctionalRole
ROLE_CHOICE: OtherRoleChoice1
ORGANISATIONAL_ROLE: Identifiable Service Delivery Location Role

Specializes: IdentifiableServiceDeliveryLocationRole

@type = Type of source

ENVIRONMENT_ROLE: Supporting or Provider Organisation Role

Specializes: SupportingOrProviderOrganisationRole

@type = Type of source

ENVIRONMENT_ROLE: Non-Identifiable Service Delivery Location Role

Specializes: NonIdentifiableServiceDeliveryLocationRole

@type = Type of source

ENTRY: GenericDischargeEvent
GENERIC_ACTIVITY_ELEMENT: GenericDischargeEvent

@obs_time = Date of discharge and Time of discharge

@meaning = Discharge Event meaning

- meaning.code.semantic = GUID for SCT expression

SCT expression:

243796009 | situation with explicit context | :
{ 363589002 | associated procedure |
= ( ( << 58000006 | patient discharge | )
AND ( ! 307838002 | discharge by person | )
AND ( ! < 306382007 | discharge by health worker | )
AND ( ! 41819004 | patient discharge, deceased, donation of body | )
AND ( ! 79779006 | patient discharge, deceased, no autopsy | )
AND ( ! 89334003 | patient discharge, deceased, to anatomic board | )
AND ( ! 12616003 | patient discharge, escaped from custody | )
AND ( ! 47031007 | patient discharge, type unclassified, explain by report | )
AND ( ! 3133002 | patient discharge, deceased, autopsy | )
AND ( ! 1917008 | patient discharge, deceased, medicolegal case | )
AND ( ! 34596002 | patient discharge, elopement | )
AND ( ! 20541009 | patient on pass | )
AND ( ! < 306685000 | discharge to establishment | )
)
, 408730004 | procedure context | = < 410523001 | post-starting action status |
, 408731000 | temporal context | = < 410510008 | temporal context value |
, 408732007 | subject relationship context | = < 125676002 | person |
}
<hasContext>

COMPONENT_RELATIONSHIP_TYPE.meaning.code.enum = hasContext

UNBOUND_DATA_ELEMENT: Discharge Method

Specialises: ** To create Domain Model **

@value: Discharge Method

-value.code.enum =

Patient discharged on clinical advice or with clinical consent,

Patient discharged him/herself or was discharged by a relative or advocate,

Patient discharged by mental health review tribunal; Home Secretary or court (remove for current RCP DS),

Patient died,

Stillbirth

<destination>

ENTRY.other_participants is of type PARTICIPATION

PARTICIPATION.type = DST -- Discharge Destination

FUNCTIONAL_ROLE_CHOICE: OtherParticipationsChoice
FUNCTIONAL_ROLE:OtherFunctionalRole
ROLE_CHOICE: OtherRoleChoice1
ORGANISATIONAL_ROLE: IdentifiableServiceDeliveryLocationRole

@type = Type of destination

@address = Destination address

ORGANISATIONAL_ROLE:IdentifiableOrganisationalRole

@id = Organisation Id

@type = Type of destination

@address = Destination address

ENVIRONMENT_ROLE: NonIdentifiableServiceDeliveryLocationRole

@type = Type of destination

@address = Destination address (not required if patient's home)

ENVIRONMENT_ROLE: SupportingOrProviderOrganisationRole

@type = Type of destination

@address = Destination address

<discharger>

ENTRY.other_participants is of type PARTICIPATION

PARTICIPATION.type = DIS

<PERSON ROLE>: IdentifiablePersonInOrganisationRole

@id = ODS.Hospital Consultants

<played by>
PERSON_ENTITY: PersonEntity

@name = Consultant name --unstructured

<scoped by>
ENVIRONMENT_ROLE: NonIdentifiableServiceDeliveryLocationRole

@type: clinicalTreatmentSpecialtyCodes (values same as mainSpecialty code in Data Dictionary??)

<played by>
PLACE_ENTITY: PlaceEntity

@name = Name of specialty or department discharging patient

<distribution>

ENTRY.other_participants is of type PARTICIPATION

PARTICIPATION.type = PRCP (Primary information recipient)

FUNCTIONAL_ROLE_CHOICE: OtherParticipationsChoice
FUNCTIONAL_ROLE:Participation
ROLE_CHOICE: OtherRoleChoice2
PERSON_ROLE: ThirdPartyRole

Specialises: ThirdPartyRole

@type =LRAVocab.ThirdPartyRole_types

PERSON_ROLE:identifiablePersonInOrganisationRole

Specialises: IdentifiablePersonInOrganisationRole

@type = LRAVocab.IdentifiablePersonInOrganisationRole_types

Note: What is the definition for Proxy and does Other include Other Professionals or Other Third party relations etc.???

PERSON_ROLE: SubjectOfCareRole

Specialises: SubjectOfCareRole

@type = LRAVocab.SubjectOfCareRole_types

ORGANISATION_ROLE:IdentifiableOrganisationRole

Specialises: IdentifiableOrganisationRole

@type = LRAVocab.IdentifiableOrganisationRole_types

ORGANISATION_ROLE:IdentifiableServiceDeliveryLocationRole

Specialises: :IdentifiableServiceDeliveryLocationRole

@type = LRAVocab.IdentifiableServiceDeliveryLocationRole_types

ENVIRONMENT_ROLE:SupportingOrProviderOrganisationRole

Specialises: SupportingOrProviderOrganisationRole

@type = LRAVocab.SupportingOrProviderOrganisationRole_types

<subjectOfCare>

ENTRY.other_participants is of type PARTICIPATION

PARTICIPATION.type = SUBJ (subject of care) ** To be added **

FUNCTIONAL_ROLE_CHOICE:OtherParticipationsChoice
PARTICIPATION:Participation

@type = SUBJ (subject of care) ** To be added **

ROLE_CHOICE:OtherRoleChoice2
<PERSON_ROLE>: SubjectOfCareRole

@id:II = NHS Number or other unique identifier of the patient

@address(use=home) = Patient address --Structured address

@telecom = Patient telephone number(s)

<played by>
<PERSON_ENTITY>: PersonEntity

@name: EN.PN.NhsStandard

- name.part(type=family) = Patient surname

- name.part(type=given) = Patient forename

- name.part(type=given; use=pseudonym) = Name known as

@birthTime = Date of Birth

@gender = Gender

{Male, Female, Other Specific, Not Known, Not Specified}

<registered with>

ROLE_RELATIONSHIP.type = registered with

** Amendment required - Relationship does not currently exists in SubjectOfCare Domain Model **

<PERSON_ROLE>: IdentifiablePersonInOrganisationRole

@id: II = GMC Code

<played by>
<PERSON_ENTITY>: PersonEntity

@name = GP Name -- structured/unstructured??

<is scoped by>

ROLE_RELATIONSHIP.type = is scoped by

<PERSON_ROLE>: IdentifiableOrganisationRole

@id = GP Practice Code

@address = GP Practice address

<played by>
ORGANISATION_ENTITY: OrganisationEntity
<composer>

COMPOSITION.composer is of type FUNCTIONAL_ROLE

FUNCTIONAL_ROLE_CHOICE:ComposerChoice
FUNCTIONAL_ROLE:ComposerFunctionalRole
ROLE_CHOICE:ComposerRoleChoice
<composed by>
PERSON_ROLE: IdentifiablePersonInOrganisationRole

@type = Person authoring data grade -- (Roles include : [0..1] Consultant, Doctor, Nurse)

@mainSpecialtyCode = Person authoring data Specialty

@clinicalTreatmentSpecialtyCode = Person authoring data Treatment Speciality -- ** To be added

<played by>
<Person Entity>: PersonEntity

@name = Person authoring data name

<committal>

COMPOSITION.committal is of type AUDIT_INFO

AUDIT_INFO:AuditInfo

Can there be another domain model Committer of type AUDIT_INFO ??

@committer:II = ** Should there be an Id of the person committing the discharge summary??***

@version_set_id: II = Document version

@version_status = VER01 (finished) ??? -- *** Useful to have this attribute to indicate whether the version of the discharge summary committed is VER00-draft, VER01 - finished, VER02 - update, VER03 - correction, VER04 - deletion

PERSON_ROLE: IdentifiablePersonInOrganisationRole

@id:II =** Should there be an Id of the person committing the discharge summary??***

@type = Person entering data grade

@mainSpecialityCode = Person entering data Specialty -- Will a consultant ever be the committer of the discharge summary?

@treatmentFunctionCode = Person entering data Treatment Speciality -- ** To be added

<played by>
PERSON_ENTITY:PersonEntity

@name = Person entering data name

<attestations>

*** Add ATTESTATION_INFO to Domain Model. ***

**Add relationship type subsequently ***

COMPOSITION.attestations is of type ATTESTATION_INFO

ATTESTATION_INFO: Attestation info

** ATTESTATION_INFO Domain Model to be created **

@time = Discharge summary verification date -- Requires ATTESTATION_INFO domain model to meet requirement

<attester>

ATTESTATION_INFO.attester is of type FUNCTIONAL_ROLE

FUNCTIONAL_ROLE: Attester Role

** Requires Attester Functional Role Domain Model **

<played by>
PERSON_ROLE: IdentifiablePersonInOrganisationRole

@id = Consultant Code --Should the consultant id be captured for person verifying the discharge summary?

@type = Person verifying data grade

@mainSpecialtyCode = Person verifyng data Specialty

@treatmentFunctionCode = Person verifying data Treatment Speciality -- *** To be added

<played by>
PERSON_ENTITY: PersonEntity

@name = Person verifying data name