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

Contents
# Requirements Specification for Person Authoring Data
Details of the healthcare professional(s) authoring the summary. [Adapted from 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)]. Includes ‘the name and position of the person to whom questions about the content of the Discharge Summary may be addressed, and complete and accurate contact details (including a telephone number) for that person. [2011/12 Standard Terms and Conditions for Acute Hospital Services (Department of Health, April 2011)]. Includes ‘contact details for the Provider’s facility’. [2011/12 Standard Terms and Conditions for Acute Hospital Services (Department of Health, April 2011)].
## Person Authoring Data Name ### Business Definition Name of the person who takes overall responsibility for the complete discharge summary data. ### Requirement Reference - LRA DS expert group 2011 – for data provenance. - Keeping patients safe when they transfer between care providers – getting the medicines right, Part 1: Good practice guidance for health professions, Royal Pharmaceutical Society (Final Draft 06/06/2011). ### Proposed Data Values [Prefixes][Given names][Family names][Suffixes]. ### Data Use Data provenance (used locally only). ### Data Source EHR system user identification. ### Available Data Standards ISO 21090 Health informatics data types, HL7 V3 Data Types, NHS MIM data types.
## Person Authoring Data Grade ### Business Definition Grade of the person who authored the data. ### Requirement Reference - LRA DS expert group 2011 – for data provenance. - Equivalent to ‘job title’ in Keeping patients safe when they transfer between care providers – getting the medicines right, Part 1: Good practice guidance for health professions, Royal Pharmaceutical Society (Final Draft 06/06/2011). ### Proposed Data Values Grade of person authoring data. ### Data Use Follow up care / contact. ### Data Source System sign on, manual entry by exception. ### Available Data Standards As per the Job Roles National Workforce Dataset v2.2.
## Person Authoring Data Specialty ### Business Definition Speciality of the person who authors the discharge summary data. ### Requirement Reference LRA DS expert group 2011 – for data provenance. ### Proposed Data Values Speciality of person authoring data. ### Data Use Follow up care. ### Data Source System sign on, manual entry by exception. ### Available Data Standards Specialty of a Consultant as per the National Workforce Dataset (NWD) v2.2.
## Person Authoring Data Treatment Speciality ### Business Definition Treatment Speciality is based on specialty, but also includes approved sub-specialties and treatment specialties used by lead care professionals including hospital consultants. ### Requirement Reference LRA DS expert group 2011 – for data provenance. ### Proposed Data Values Treatment Speciality of person authoring data. ### Data Use Follow up care. ### Data Source PAS. ### Available Data Standards NHS Data Model & Dictionary Version 3 Treatment Function Code.
## Contact Telephone Numbers ### Business Definition Telephone number(s) associated with the person authoring the Discharge Summary. ### Requirement Reference Keeping patients safe when they transfer between care providers – getting the medicines right, Part 1: Good practice guidance for health professions, Royal Pharmaceutical Society (Final Draft 06/06/2011). ### Proposed Data Values 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.
## Discharge Summary Authoring Date ### Business Definition Date and time the discharge summary data was authored. ### Requirement Reference - LRA DS expert group 2011 – for data provenance. - Keeping patients safe when they transfer between care providers – getting the medicines right, Part 1: Good practice guidance for health professions, Royal Pharmaceutical Society (Final Draft 06/06/2011). ### Proposed Data Values A string with the format "YYYYMMDDHHMMSS.UUUU[+|-ZZzz]". ### Data Use Policy requirements. ### Data Source System generated time and date stamp for ‘last modified on’, manual entry by exception. ### 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.