# 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 Constrained Domain Model: Diagnosis
A constrained ELEMENT to represent a diagnosis that is present at the time of discharge as well as any diagnoses that were resolved during this admission of the subject of care. Diagnoses are decisions arrived at as a result of a synthesis of signs, symptoms, investigations (i.e. findings), and theoretical knowledge. These include diseases, disorders, syndromes and physiological states such as pregnancy1. 1. NPFIT-NCR-DES-0135.07 NHS Care Record Elements ## Specializes ## DiagnosisName ## 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 Relationships
Object Class | Name | Occurs | Dependency | Specified by
--- | --- | --- | --- | ---
Text | HasAnnotation | 0..* | INDEPENDENT | Diagnosis
CurrentMedicationActivity | IsIndicationOf | 0..* | INDEPENDENT | Diagnosis
StoppedMedicationActivity
CareIssues | IsClinicalContextOf | 0..* | INDEPENDENT | Diagnosis
Diagnosis | IsComplicatedBy | 0..* | INDEPENDENT | Diagnosis
ProcedureActivity
DiagnosisStatus | HasRecordRole | 0..1 | INDEPENDENT | Diagnosis
### Object Relationships
Subject Class | Name | Occurs | Dependency | Specified by
--- | --- | --- | --- | ---
ReasonForAdmission | IsConsequenceOf | 0..* | INDEPENDENT | ReasonForAdmission
ReasonForAdmission | IsConsequenceOf | 0..* | INDEPENDENT | ReasonForAdmission
CareIssues | HasClinicalContext | 0..* | INDEPENDENT | CareIssues
CurrentMedicationActivity | HasIndication | 0..* | INDEPENDENT | CurrentMedicationActivity
Diagnosis | IsComplicatedBy | 0..* | INDEPENDENT | Diagnosis
ProcedureActivity | Complicates | 0..* | INDEPENDENT | ProcedureActivity
ProcedureActivity | HasIndication | 0..* | INDEPENDENT | ProcedureActivity
StoppedMedicationActivity | HasIndication | 0..* | INDEPENDENT | StoppedMedicationActivity
## Item of ENTRY Constrained Domain Models ### AdmissionRelatedInformation ### CareIssues ### CurrentMedicationActivity ### Diagnosis ### ProcedureActivity ### StoppedMedicationActivity ## Reference Model Type ## FINDING_OBSERVATION_ELEMENT