# COMPOSITION: Discharge Summary

COMPOSITION: Discharge Summary

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

<record target>

COMPOSITION.other_participations is of type PARTICIPATION

PARTICIPATION:

@type = RCT

PERSON_ROLE: Patient Role

Specializes: SubjectOfCareRole

@id: II.NhsNumber = NHS Number

@address (use=home) = Patient address

- structured or unstructured? If structured which address parts are allowable?

@telecom = Patient telephone number(s)

<played by>
PERSON_ENTITY: Person Entity

Specializes: 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

<registered with>

ROLE_RELATIONSHIP.type = registered with

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

PERSON_ROLE: GP Role

Specializes: IdentifiablePersonInOrganisationRole

@id.nullFlavor.enum = NA

<played by>
PERSON_ENTITY: Person Entity

Specializes: PersonEntity

@name = GP Name

- structured or unstructured name?

<is scoped by>

ROLE_RELATIONSHIP.type = is scoped by

ORGANISATIONAL_ROLE: GP Practice Role

Specializes: IdentifiableOrganisationalRole

@id = GP practice code

@address = GP practice address

ENTRY: Admission Details

** New ENTRY Domain Model required **

???_ELEMENT: Admission

** New ENTRY Domain Model required **

Is this an admission event or procedure (i.e. FINDING_OBSERVATION_ELEMENT or GENERAL_ACTIVITY_ELEMENT)?

Will the event/procedure include admission method/source?

@obs_time = Date of admission and Time of admission

<location>

ENTRY.other_participants is of type PARTICIPATION

PARTICIPATION.type = LOC

ORGANISATIONAL_ROLE: Hospital Site Role

Specializes: IdentifiableOrganisationalRole

What details are required of hospital site - id, name, address, telecom details?

= Hospital site

<is scoped by>
ORGANISATIONAL_ROLE: Hospital Trust Role

Specializes: IdentifiableOrganisationalRole

What details are required of hospital trust - id, name, address, telecom details?

= Responsible trust

ENTRY: Discharge Details

** New ENTRY Domain Model required **

???_ELEMENT: Discharge

** New ENTRY Domain Model required **

Is this a discharge event or procedure (i.e. FINDING_OBSERVATION_ELEMENT or GENERAL_ACTIVITY_ELEMENT)?

Will the event/procedure include discharge method?

@obs_time = Date of discharge and Time of discharge

<has care context>
FINDING_OBSERVATION_ELEMENT: Home Environment Status

** New ENTRY Domain Model required **

@meaning = Living alone (105529008 | lives alone | with finding context = definitely present OR definitely not present?)

<destination>

ENTRY.other_participants is of type PARTICIPATION

PARTICIPATION.type = DST

ORGANISATIONAL_ROLE: Identifiable Service Delivery Location Role

Specializes: IdentifiableServiceDeliveryLocationRole

@type = Type of destination

@address = Destination address

ENVIRONMENT_ROLE: Supporting or Provider Organisation Role

Specializes: SupportingOrProviderOrganisationRole

@type = Type of destination

@address = Destination address

ENVIRONMENT_ROLE: Non-Identifiable Service Delivery Location Role

Specializes: NonIdentifiableServiceDeliveryLocationRole

@type = Type of destination

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

<attender>

ENTRY.other_participants is of type PARTICIPATION

PARTICIPATION.type = ATND

PERSON_ROLE: HCP Role

Specializes: IdentifiablePersonInOrganisationRole

@mainSpecialtyCode = Discharging specialty/department

Is this specific to the discharge event/procedure or is it consultant applicable at the discharge summary level?

What details are required for the consultant?

<composer>

COMPOSITION.composer is of type FUNCTIONAL_ROLE

PERSON_ROLE: HCP Role

Specializes: IdentifiablePersonInOrganisationRole

@id.nullFlavor.enum = NA

@type = Grade

** Specialty - currently only have mainSpecialtyCode for consultants. Is this 'inherited' by all member's of the consultant's team? **

<played by>
PERSON_ENTITY: Person Entity

Specializes: PersonEntity

@name = Doctor's name

- structured or unstructured name?

<primary information recipient>

COMPOSITION.other_participants is of type PARTICIPATION

PARTICIPATION.type = PRCP

Primary information recipients or trackers (or both?)

What details are required for each?

= Distribution List

ENTRY: Provision of Advice and Information

** New ENTRY domain model required **

GENERAL_ACTIVITY_ELEMENT: Discharge Discussion

Specializes: GenericDiscussion

@meaning = <<223482009 | discussion |

- (should this be 409073007 | education | ?)

- subject relationship context = Differentiation required between information given to patients, carers and any other authorised representatives (details of subjects other than patient required?)

<has annotation>
UNBOUND_DATA_ELEMENT: Advice and Information Provided

Specializes: Text

@value = Information given to patient and/or authorised representative

GENERAL_ACTIVITY_ELEMENT: Provision of Written Advice

** New ELEMENT domain model required **

@meaning = SNOMED CT concept equivalent to 'provision of written advice' ?

- subject relationship context = Differentiation required between information given to patients, carers and any other authorised representatives (details of subjects other than patient required?)

<has annotation>
UNBOUND_DATA_ELEMENT: Advice and Information Provided

Specializes: Text

@value = Information given to patient and/or authorised representative

ENTRY: Concerns, Expectations and Wishes

** New ENTRY domain model required **

FINDING_OBSERVATION_ELEMENT: Concerns

** New ELEMENT domain model required **

@meaning = SNOMED CT concept equivalent to finding of 'patient exhibits concern' ?

<has annotation>
UNBOUND_DATA_ELEMENT: Concerns, Expectations and Wishes

Specializes: Text

@value = Patient's concerns, expectations and wishes

FINDING_OBSERVATION_ELEMENT: Expectations

** New ELEMENT domain model required **

@meaning = SNOMED CT concept equivalent to finding of 'patient exhibits expectations' ?

<has annotation>
UNBOUND_DATA_ELEMENT: Concerns, Expectations and Wishes

Specializes: Text

@value = Patient's concerns, expectations and wishes

FINDING_OBSERVATION_ELEMENT: Wishes

** New ELEMENT domain model required **

@meaning = SNOMED CT concept equivalent to finding of 'patient exhbits wishes/preferences' ?

<has annotation>
UNBOUND_DATA_ELEMENT: Concerns, Expectations and Wishes

Specializes: Text

@value = Patient's concerns, expectations and wishes