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

Contents
The content of this release is not comprehensive and is not fully validated and must not be used in live system implementations.
# ELEMENT Domain Model: DiagnosisName
An ELEMENT to represent the clinical nature of a diagnosis5. Diagnoses are decisions about the nature of a condition arrived at as a result of a synthesis of signs, symptoms, investigations (i.e. findings), and theoretical knowledge. Conditions that may be diagnoses include diseases, disorders, syndromes and physiological states such as pregnancy5. The recording of a Diagnosis should be seen as being true at a particular point in time. A Care Professional will make a Diagnosis using the information available at that time. Diagnoses will potentially progress over time as new information becomes available2. In common with other finding observations, a Diagnosis Name is intended to fully represent the clinically relevant nature of a clinical finding. It is distinguished as a diagnosis of a particular type by its link to a Diagnosis Tag. A Diagnosis Name may be associated with more than one Diagnosis Tag(s). For example, a provisional working diagnosis may subsequently be ascribed the status of primary diagnosis5. 2: NPFIT-NCR-DES-0135.07 NHS Care Record Elements 5: NPFIT-FNT-TO-DPM-0931.05 SNOMED CT Bindings for Common Recording Patterns ## Attributes
Name | Data type | Occurs | Description | Value Constraints
--- | --- | --- | --- | ---
name | SC | 1..1 | The name, expressed as a coded value or as plain text, specifies the clinical or administrative concept to which this EHR node corresponds, as labelled in the EHR system in which it was first committed. |
value
Literal value(s): FINDING_OBSERVATION_ELEMENT
rc_id | II.Uuid | 1..1 | The globally-unique identifier by which this node in the EHR hierarchy is referenced in the EHR system to which the data were first committed. This identifier shall be retained by the EHR Recipient and re-used whenever this RECORD_COMPONENT is subsequently included in another EHR_EXTRACT. |
meaning | CD.CV | 1..1 | A coded representation of the diagnosis. |
code
Semantic expression constraint
synthesised | BL | 1..1 | This attribute value shall be TRUE if this RECORD_COMPONENT has been created in order to comply with this standard , but this point in the EHR hierarchy has no corresponding node in the EHR from which it was extracted. |
policy_ids | II | 0..* | This attribute identifies one or more access control policies that specifically pertain to this RECORD_COMPONENT and which need to be communicated to the EHR Recipient to govern future access to it. The identifiers may refer to policy information included in this EHR_EXTRACT as defined in EN 13606-4:2007, or to policies held in external policy servers to which the EHR Recipient has access. |
obs_time | IVL_TS | 0..1 | The date and time, or interval, at which the diagnosis held. |
value | ANY | 1..1 | An ELEMENT has a single DATA_VALUE containing the value, unless this is indicated as absent by a null_flavour attribute. |
nullFlavor
Literal value(s): NA
## COMPONENT RELATIONSHIPS ### Subject of relationships
Name | Object of relationship | Occurs | Dependency
--- | --- | --- | ---
IsComplicatedBy | DiagnosisName | 0..* | INDEPENDENT
IsComplicatedBy | GenericProcedure | 0..* | INDEPENDENT
HasAnnotation | Text | 0..* | INDEPENDENT
IsInterpretationOf | BloodPressureObservation | 0..* | INDEPENDENT
IsInterpretationOf | BodyHeightObservation | 0..* | INDEPENDENT
IsInterpretationOf | BodyWeightObservation | 0..* | INDEPENDENT
IsInterpretationOf | GenericFindingObservation2 | 0..* | INDEPENDENT
IsInterpretationOf | GenericPropertyObservation | 0..* | INDEPENDENT
IsInterpretationOf | TemperatureObservation | 0..* | INDEPENDENT
IsInterpretationOf | GenericPropertyObservation2 | 0..* | INDEPENDENT
IsInterpretationOf | GenericFindingObservation | 0..* | INDEPENDENT
HasRecordRole | DiagnosisTag | 0..* | DEPENDENT_OBJECT
HasConsequence | GenericTreatment | 0..* | INDEPENDENT
IsClinicalContextOf | GenericProblemAndIssue | 0..* | INDEPENDENT
IsIndicationOf | ProductOrSubstanceRelatedActivity | 0..* | INDEPENDENT
### Object of relationships
Name | Subject of relationship | Occurs | Dependency
--- | --- | --- | ---
HasClinicalContext | GenericAdmissionEvent | 0..* | INDEPENDENT
HasClinicalContext | GenericAdmissionEvent2 | 0..* | INDEPENDENT
HasIndication | GenericTreatment | 0..* | INDEPENDENT
HasInterpretation | GenericFindingObservation | 0..* | INDEPENDENT
HasIndication | ProductOrSubstanceRelatedActivity | 0..* | INDEPENDENT
HasClinicalContext | GenericProblemAndIssue | 0..* | INDEPENDENT
HasIndication | GenericProcedure | 0..* | INDEPENDENT
HasIndication | ProductOrSubstanceRelatedActivity2 | 0..* | INDEPENDENT
IsComplicatedBy | DiagnosisName | 0..* | INDEPENDENT
Complicates | GenericProcedure | 0..* | INDEPENDENT
## Item of ENTRY Domain Models ### GenericAdmissionEvent ### GenericFinding ### GenericProblemAndIssue ### GenericProcedure ### ProductOrSubstanceRelatedActivity ### GenericAdmissionEvent2 ### Diagnosis ### GenericTreatment ### ProductOrSubstanceRelatedActivity2 ## Reference Model Type ## FINDING_OBSERVATION_ELEMENT