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

Contents
# Requirements Specification for Operations And Significant Procedures
Descriptions of new and relevant therapeutic operations and procedures, including any complications and adverse events arising during the procedure. Note: Procedures that are both therapeutic and investigative may appear either in this section or in the Investigations section or in both, at the author’s discretion. Requirement References: - 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). - Requirement for ‘details of any clinical procedure undertaken’ in 2011/12 Standard Terms and Conditions for Acute Hospital Services (Department of Health, April 2011).
## Procedure Performed Date ### Business Definition The start date and optionally time when the procedure was performed. ### Requirement Reference LRA DS expert group 2011 – clinically useful for follow-up care. ### Proposed Data Values A string with the format "YYYYMMDDHHMMSS.UUUU[+|-ZZzz]". ### Data Use Clinical audit / research, continuing care. ### 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.
## Procedure Description ### Business Definition A description of the therapeutic procedure performed. The procedure description could include the site and should include laterality where applicable. It may also include the status of the procedure and priority information, at the discretion of the author. For data entry, some sites may prefer to require authors to enter some of the description separately (e.g. laterality) where it is applicable. The communication form, however, should be a single expression. ### 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). - Medicines Reconciliation: A Guide to Implementation (National Prescribing Centre, 2008). ### Proposed Data Values Coded expression for name, site, laterality and potentially also status and priority. 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). - Name - Site - Laterality - Post-starting action status (at time of discharge): *Suspended *Performed (Done) *Discontinued (Stopped before completion) *Abandoned (Stopped before completion) [Context values for actions_EDC_19032009.doc] - Priority * Immediate * Urgent * Elective * Scheduled ### Data Use Clinical audits / research, continuing care. ### Data Source Copied from previous record entry. ### Data Examples - Elective, Right colectomy, performed - Emergency, Appendectomy, performed - Insertion of Chest Drain, right ### Available Data Standards SNOMED CT.
## Consultant Responsible Name ### Business Definition The consultant responsible for undertaking the procedure. ### Requirement Reference LRA DS expert group 2011 – useful for potential follow-up contact. ### Proposed Data Values [Prefixes][Given names][Family names][Suffixes]. ### Data Use Follow-up contact. ### Data Source Previous record entry. ### Available Data Standards ISO 21090 Health informatics data types, HL7 V3 Data Types, NHS MIM data types.
## Consultant Responsible ID ### Business Definition The Consultant’s identification code. ### Requirement Reference LRA DS expert group 2011 – to add precision to Consultant Responsible Name. ### Proposed Data Values Consultant unique identifier. ### Data Use Clinical audit, continuing care. ### Data Source Copied from previous record entry. ### Available Data Standards General Medical Council code.
## Indications For Procedure ### Business Definition The primary clinical reason(s) for the procedure performed. ### Requirement Reference LRA DS expert group 2011 – allowance for additional detail at the discretion of the author. ### Proposed Data Values Coded expressions for diagnosis, finding or problem also recorded elsewhere in the Discharge Summary. 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 Clinical audit, continuing care. ### Data Source Copied from previous record entry. ### Data Examples - Carcinoma of hepatic flexure - Abdominal pain, left iliac fossa - Right Pneumothorax ### Available Data Standards SNOMED CT.
## Procedure Comments ### Business Definition Any additional comments about a procedure. ### Requirement Reference LRA DS expert group 2011 – allowance for additional detail at the discretion of the author. ### Proposed Data Values Free text. ### Data Use Continuing care. ### Data Source Copied from previous record entry.
## Complications During Procedure ### Business Definition Details of any intra-operative complications encountered during the procedure or arising during the patient’s stay in the recovery unit. ### 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 Values A coded expression describing the complication. 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 Clinical audit / research, continuing care. ### Data Source Copied from procedure record. ### Data Examples - Cardiac arrest - Fracture of femur (during hip replacement) - Liver laceration (during cholecystectomy) ### Available Data Standards SNOMED CT.