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

Contents
# Requirements Specification for Community And Specialist Services Advice Recommendations And Future Plan
Actions requested/planned/agreed directly with community services (community matron, palliative care, specialist nurse practitioner, rehab team, social services and community service). Actions via the GP for these services would be recorded as advice to the GP. To include: - Action. - Person responsible. - Appropriate date and time. 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).
## Community And Specialist Services Actions ### Business Definition Advice, recommendations or plan actions directed to community and specialty services. ### 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 Value Free text. ### Data Use Patient information and continuing care. ### Data Source Copied from previous record or new entry.
## Service Organisation Responsible For Action ### Business Definition The organisation responsible for taking a community or specialist service action. To be used only if the responsibility lies with an organisation rather than an individual. ### 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 Value Organisation codes. ### Data Use Contact, information for patient and follow-up care. ### Data Source Copied from previous record or new entry. ### Available Data Standards Organisational code used within the NHS England and Wales and provided and maintained by SDS.
## Contact Person ### Business Definition Service person who may be contacted concerning this action. ### 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 Value [Prefixes][Given names][Family names][Suffixes]. ### Data Use Contact. ### Data Source Copied from previous record entry or new record entry. ### Available Data Standards ISO 21090 Health informatics data types, HL7 V3 Data Types, NHS MIM data types.
## Contact Address ### Business Definition The address of the service. ### Requirement Reference LRA DS expert group 2011 – useful for contact. ### Proposed Data Value Address Prefix, Building Name and Building Number; Dependent Street or Road Name, and Street or Road Name; Dependent Locality and Double dependent locality; Postal Town; Postal County; Postal Code; PAF Key - unique ID for an address allocated by the Royal Mail. ### Data Use Contact. ### Data Source Copied from previous record / PAS. ### Available Data Standards BS7666 address standard, ISB 1500: Common User Interface - Address Input and Display.
## Contact Telephone Numbers ### Business Definition Telephone numbers associated with the service. ### Requirement Reference LRA DS expert group 2011 – useful for contact. ### Proposed Data Value Telephone number(s), with an optional 'Use' code or set of codes which may be assigned to differentiate number type : - home - primary home - vacation home - work place - direct (to the person) - public - temporary - answering service - emergency contact - mobile contact - pager (NOTE: more than one of the use descriptions above may apply to the same number). ### Data Use Contact. ### Data Source Previous record entry or new entry. ### Available Data Standards e-GIF GDSC standard for UK Telephone Number, ISB 1508: Common User Interface - Telephone Number Input and Display, Telecommunication Address Use codes from ISO 21090.
## Date For Actions ### Business Definition The date(s) and optionally time when the action is planned to be executed. ### 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 Value A string with the format "YYYYMMDDHHMMSS.UUUU[+|-ZZzz]". ### Data Use Patient information, continuing care. ### Data Source Copied from previous record or new 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.