# COMPOSITION: Discharge Summary

COMPOSITION: Discharge Summary

@session_time.high.value = Date of completion of discharge record And/Or Discharge summary authoring date ??

@session_time.low.value = Discharge summary authoring date ??

ENTRY: Admission Details

Specialises: GenericAdmissionEvent

GENERIC_ACTIVITY_ELEMENT:Admission Event

Specialises GenericAdmissionEvent

@obs_time = Date of admission and Time of admission

@meaning = Admission Event meaning

- meaning.code.semantic - GUID for SCT expression

SCT expression:

243796009 | situation with explicit context | :
{ 363589002 | associated procedure | = ( 305056002 | admission procedure | :
~ 260870009 | priority |
= ( ( 103390000 | elective | )
OR ( 25876001 | emergency | )
)
)
, 408730004 | procedure context | = < 410523001 | post-starting action status |
, 408731000 | temporal context | = < 410510008 | temporal context value |
, 408732007 | subject relationship context | = < 125676002 | person |
}
<hasContext>
UNBOUND_DATA_ELEMENT: Admission Method

Specialises: ** To create Domain Model **

@value: CD.CV = Admission Method values

value.code.enum =

Elective waiting list admission,

Elective booked admission,

Elective planned admission,

Emergency Accident and emergency or dental casualty department of the Health Care Provider,

Emergency admission after a request for immediate admission has been made direct to a Hospital Provider i.e. not through a Bed bureau by a GENERAL PRACTITIONER or deputy,

Emergency admission Consultant Clinic of this or another Health Care Provider,

Emergency admitted from the Accident And Emergency Department of another provider where they had not been admitted,

Emergency transfer of an admitted PATIENT from another Hospital Provider in an emergency,

Emergency baby born at home as intended,

Maternity admission admitted ante-partum,

Maternity admission admitted post-partum,

Birth of a baby in this Health Care Provider,

Baby born outside the Health Care Provider except when born at home as intended,

Transfer of any admitted patient from other Hospital Provider other than in an emergency

<location>

ENTRY.other_participants is of type PARTICIPATION

PARTICIPATION.type = LOC

<ORGANISATIONAL_ROLE>: Hospital Site Role

Specialises: IdentifiableOrganisationalRole

@id: II = Hospital Site id

<played by>
ORGANISATION_ENTITY: Hospital

Specialises: OrganisationEntity

@name = Hospital Site Name --unstructured

<is scoped by>

ROLE_RELATIONSHIP.type = is scoped by

<ORGANISATIONAL_ROLE>: Hospital Trust Role

Specialises: IdentifiableOrganisationalRole

@id: II = Hospital Trust id

<played by>
ORGANISATION_ENTITY: Hospital Trust
<source>

ENTRY.other_participants is of type PARTICIPATION

PARTICIPATION.type = ORG (origin) --Admission Source

FUNCTIONAL_ROLE_CHOICE: OtherParticipationsChoice
FUNCTIONAL_ROLE:OtherFunctionalRole
ROLE_CHOICE: OtherRoleChoice1
ORGANISATIONAL_ROLE: Identifiable Service Delivery Location Role

Specializes: IdentifiableServiceDeliveryLocationRole

@type = Type of source

ENVIRONMENT_ROLE: Supporting or Provider Organisation Role

Specializes: SupportingOrProviderOrganisationRole

@type = Type of source

ENVIRONMENT_ROLE: Non-Identifiable Service Delivery Location Role

Specializes: NonIdentifiableServiceDeliveryLocationRole

@type = Type of source

ENTRY: Discharge Details

Specialises: GenericDischargeEvent

GENERIC_ACTIVITY_ELEMENT: Discharge Event

Specialises: GenericDischargeEvent

@obs_time = Date of discharge and Time of discharge

<hasContext>
UNBOUND_DATA_ELEMENT: Discharge Method

Specialises: ** To create Domain Model **

@value: Discharge Method

-value.code.enum =

Patient discharged on clinical advice or with clinical consent,

Patient discharged him/herself or was discharged by a relative or advocate,

Patient discharged by mental health review tribunal; Home Secretary or court (remove for current RCP DS),

Patient died,

Stillbirth

<destination>

ENTRY.other_participants is of type PARTICIPATION

PARTICIPATION.type = DST -- Discharge Destination

FUNCTIONAL_ROLE_CHOICE: DischargeDestinationChoice

Specialises: OtherParticipationsChoice

FUNCTIONAL_ROLE:OtherFunctionalRole
ROLE_CHOICE:DestinationRoleChoice

Specialises: OtherRoleChoice1

<ORGANISATIONAL_ROLE>: HighSecurityPsychiatricAccommodationRole

Specialises: IdentifiableOrganisationRole

@id: ODS.Care Trusts

@type: DST (LRA Vocab for Destination) or 62480006 | psychiatric hospital |

<played by>
ORGANISATION_ENTITY: NHSTrust

Specialises: OrganisationEntity

@description = "Repatriation from high security psychiatric accommodation in an NHS Hospital Provider (NHS Trust)"

<ENVIRONMENT_ROLE>: JudiciaryRole

Specialises: SupportingOrProviderOrganisationRole

@id: ????

@type: DST (LRA Vocab for Destination) OR 257592000 | courthouse |

<played by>
ORGANISATION_ENTITY: Court

Specialises: OrganisationEntity

@description = "Court"

<ENVIRONMENT_ROLE>: UsualPlaceOfResidenceRole

Specialises: NonIdentifiableServiceDeliveryLocationRole

@type: DST (LRA Vocab for Destination) or 264362003 | home |

<played by>
PLACE_ENTITY: ResidentialHome

Specialises: PlaceEntity

@description = "Usual place of residence unless listed below, for example, a private dwelling whether owner occupied or owned by local authority, housing association or other landlord. This includes wardened accommodation but not residential accommodation where health care is provided. It also includes PATIENTS with no fixed abode."

<ENVIRONMENT_ROLE>: TemporaryPlaceOfResidenceRole

Specialises: NonIdentifiableServiceDeliveryLocationRole

@type: DST (LRA Vocab for Destination) or 285202004 | community environment |

<played by>
PLACE_ENTITY: OtherResidence

Specialises: PlaceEntity

@description = "Temporary place of residence when usually resident elsewhere (includes hotel, residential educational establishment)."

<ENVIRONMENT_ROLE>: PenalRole

Specialises: SupportingOrProviderOrganisationRole

@id: ODS.Prison codes ???

@type: DST (LRA Vocab for Destination) OR 257656006 | penal institution |

<played by>
ORGANISATION_ENTITY: PenalEstablishment

Specialises: OrganisationEntity

@description = "Penal establishment or police station"

<ORGANISATIONAL_ROLE>: HighSecurityPsychiatricAccommodationRole

Specialises: IdentifiableOrganisationRole

@id: ODS.Care Trusts (do they have identifiers for Scotland psychiatric hospital units) ???

@type: DST (LRA Vocab for Destination) or 62480006 | psychiatric hospital |

<played by>
ORGANISATION_ENTITY: PsychiatricHospitalScotland

Specialises: OrganisationEntity

@description = "High Security Psychiatric Hospital, Scotland"

<ENVIRONMENT_ROLE>:HighSecurityPsychiatricAccomodationRole

Specialises: NonIdentifiableServiceDeliveryRole

@type: DST (LRA Vocab for Destination) or 62480006 | psychiatric hospital | ?? (general hospital SCT code ??)

<played by>
PLACE_ENTITY:PsychiatricAccommodation

Specialises: PlaceEntity

@description = "NHS other hospital provider - high security psychiatric accommodation"

<identified by>

ROLE_RELATIONSHIP.type = NonIdentifiableServiceDeliveryLocationRole_IdentifiableOrganisationalRole_Relationship (labeled as 'identified by')

<ORGANISATIONAL_ROLE>: NHSOtherHospitalProviderRole

Specialises: IdentifiableOrganisationalRole

@id = ODS.CareTrust ??

<played by>
ORGANISATION_ENTITY: NHSOtherHospitalProvider

Specialises: OrganisationEntity

<ENVIRONMENT_ROLE>:MediumSecurityPsychiatricAccomodationRole

Specialises: NonIdentifiableServiceDeliveryRole

@type: DST (LRA Vocab for Destination) or 62480006 | psychiatric hospital | ?? (general hospital SCT code ??)

<played by>
PLACE_ENTITY:MediumSecureUnitPsychiatricAccommodation

Specialises: PlaceEntity

@description = "NHS other hospital provider - medium secure unit" (psychiatric acccomodation or other kind of facility??? Assumption made: Psychiatric medium security unit.

<identified by>

ROLE_RELATIONSHIP.type = NonIdentifiableServiceDeliveryLocationRole_IdentifiableOrganisationalRole_Relationship (labeled as 'identified by')

<ORGANISATIONAL_ROLE>: NHSOtherHospitalProviderRole

Specialises: IdentifiableOrganisationalRole

@id = ODS.CareTrust ??

<played by>
ORGANISATION_ENTITY: NHSOtherHospitalProvider

Specialises: OrganisationEntity

<ENVIRONMENT_ROLE>:GeneralPatientOrYoungerPhysicallyDisabledWardRole

Specialises: NonIdentifiableServiceDeliveryRole

@type: DST (LRA Vocab for Destination) or suitable SCT code ??

<played by>
PLACE_ENTITY:GeneralPatientOrYoungerPhysicallyDisabledWard

Specialises: PlaceEntity

@description = "NHS other hospital provider - ward for general PATIENTS or the younger physically disabled".

<identified by>

ROLE_RELATIONSHIP.type = NonIdentifiableServiceDeliveryLocationRole_IdentifiableOrganisationalRole_Relationship (labeled as 'identified by')

<ORGANISATIONAL_ROLE>: NHSOtherHospitalProviderRole

Specialises: IdentifiableOrganisationalRole

@id = ODS.CareTrust ??

<played by>
ORGANISATION_ENTITY: NHSOtherHospitalProvider

Specialises: OrganisationEntity

<ENVIRONMENT_ROLE>:MaternityOrNeonateWardRole

Specialises: NonIdentifiableServiceDeliveryRole

@type: DST (LRA Vocab for Destination) or suitable SCT code ??

<played by>
PLACE_ENTITY:MaternityOrNeonateWard

Specialises: PlaceEntity

@description = "NHS other hospital provider - ward for maternity PATIENTS or neonates"

<identified by>

ROLE_RELATIONSHIP.type = NonIdentifiableServiceDeliveryLocationRole_IdentifiableOrganisationalRole_Relationship (labeled as 'identified by')

<ORGANISATIONAL_ROLE>: NHSOtherHospitalProviderRole

Specialises: IdentifiableOrganisationalRole

@id = ODS.CareTrust ??

<played by>
ORGANISATION_ENTITY: NHSOtherHospitalProvider

Specialises: OrganisationEntity

<ENVIRONMENT_ROLE>:MentallyIllOrLearningDisabilitiesWardRole

Specialises: NonIdentifiableServiceDeliveryRole

@type: DST (LRA Vocab for Destination) or suitable SCT code ??

<played by>
PLACE_ENTITY:MentallyIllOrLearningDisabilitiesWard

Specialises: PlaceEntity

@description = "NHS other hospital provider - ward for PATIENTS who are mentally ill or have learning disabilities"

<identified by>

ROLE_RELATIONSHIP.type = NonIdentifiableServiceDeliveryLocationRole_IdentifiableOrganisationalRole_Relationship (labeled as 'identified by')

<ORGANISATIONAL_ROLE>: NHSOtherHospitalProviderRole

Specialises: IdentifiableOrganisationalRole

@id = ODS.CareTrust ??

<played by>
ORGANISATION_ENTITY: NHSOtherHospitalProvider

Specialises: OrganisationEntity

<ORGANISATIONAL_ROLE>: NHSCareHomeRole

Specialises: IdentifiableOrganisationRole

@id: ODS.Care Home HQs and Sites

@type: DST (LRA Vocab for Destination) or suitable SCT code?

<played by>
ORGANISATION_ENTITY: NHSCareHome

Specialises: OrganisationEntity

@description = "NHS run Care Home"

<ENVIRONMENT_ROLE>: LocalAuthorityCareAccommodationRole

Specialises:SupportingOrProviderOrganisationRole

@id: ODS.Care Home HQs and Sites

@type: DST (LRA Vocab for Destination) or suitable SCT code?

<played by>
ORGANISATION_ENTITY: LocalAuthorityCareAccommodation

Specialises: OrganisationEntity

@description = "Local Authority residential accommodation ie where care is provided"

<ENVIRONMENT_ROLE>: LocalAuthorityFosterCareRole

Specialises: NonIdentifiableServiceDeliveryLocationRole

@type: DST (LRA Vocab for Destination) or suitable SCT code??

<played by>
PLACE_ENTITY: LocalAuthorityFosterCare

Specialises: PlaceEntity

@description = "Local Authority foster care"

<ENVIRONMENT_ROLE>: NonNHSMediumSecureUnitRole

Specialises: SupportingOrProviderOrganisationRole

NOTE: Is this a medium secure 'psychiatric unit'???

@id = ODS.Secondary Care Organisations

@type: DST (LRA Vocab for Destination) or 62480006 | psychiatric hospital | ?? (general hospital SCT code ??)

<played by>
PLACE_ENTITY:NonNHSMediumSecureUnit

Specialises: PlaceEntity

@description = "Non-NHS run hospital - medium secure unit" (psychiatric acccomodation or other kind of facility??? Assumption made: Psychiatric medium security unit.

<ENVIRONMENT_ROLE>: NonNHSCareHomeRole

Specialises: SupportingOrProviderOrganisationRole

@id = ODS.Secondary Care Organisations

@type: DST (LRA Vocab for Destination) or suitable SCT code ??

<played by>
PLACE_ENTITYNonHSCareHome

Specialises: PlaceEntity

@description = "Non-NHS (other than Local Authority) run Care Home"

<ENVIRONMENT_ROLE>: NonNHSHospitalRole

Specialises: SupportingOrProviderOrganisationRole

Note: Could this be an ORGANISATIONAL_ROLE. However what would the identifier be as it is a non-NHS hospital which may not have a national identifier associated with it?

@id = ODS.Secondary Care Organisations ??

@type: DST (LRA Vocab for Destination) or suitable SCT code ??

<played by>
PLACE_ENTITY:NonNHSHospital

Specialises: PlaceEntity

@description = "Non-NHS run hospital".

<ENVIRONMENT_ROLE>: NonNHSHospiceRole

Specialises: SupportingOrProviderOrganisationRole

@id = ODS.Secondary Care Organisations. Hospice

@type: DST (LRA Vocab for Destination) or 284546000 | hospice |

<played by>
PLACE_ENTITY:NonNHSHospice

Specialises: PlaceEntity

@description = "Non-NHS (other than Local Authority) run Hospice".

<discharger>

ENTRY.other_participants is of type PARTICIPATION

PARTICIPATION.type = DIS

<PERSON ROLE>: Consultant

Specialises: IdentifiablePersonInOrganisationRole

@id = ODS.Hospital Consultants

<played by>
PERSON_ENTITY: Person

Specialises: PersonEntity

@name = Consultant name --unstructured

<scoped by>
ENVIRONMENT_ROLE: DischargingSpecialtyDepartmentRole

Specialises: NonIdentifiableServiceDeliveryLocationRole

@type: clinicalTreatmentSpecialtyCodes (values same as mainSpecialty code in Data Dictionary??)

<played by>
PLACE_ENTITY: SpecialityDepartment

Specialises:PlaceEntity

@name = Name of specialty or department discharging patient

<distribution>

ENTRY.other_participants is of type PARTICIPATION

PARTICIPATION.type = PRCP (Primary information recipient)

FUNCTIONAL_ROLE_CHOICE: DischargeSummaryDistributionChoice

Specialises: OtherParticipationsChoice

FUNCTIONAL_ROLE:Participation
ROLE_CHOICE: DistributionRoleChoice

Specialises: OtherRoleChoice2

PERSON_ROLE: ThirdPartyRole

Specialises: ThirdPartyRole

@type = {Carer; Spouse or civil partner; Parent or Guardian; Son or daughter; Sibling; Grandparent; Grandchild; Uncle or aunt; Nephew or Niece; Power of Attorney}

<played by>
PERSON_ENTITY: Person
PERSON_ROLE:identifiablePersonInOrganisationRole

Specialises: IdentifiablePersonInOrganisationRole

@type = {GP; Proxy, Contact; Proxy,Communication; Proxy; Contact and Communication; Other; Carer}

Note: What is the definition for Proxy and does Other include Other Professionals or Other Third party relations etc.???

<played by>
PERSON_ENTITY: Person
PERSON_ROLE: SubjectOfCareRole

Specialises: SubjectOfCareRole

@type = Self

<played by>
PERSON_ENTITY: Person
ORGANISATION_ROLE:IdentifiableOrganisationRole

Specialises: IdentifiableOrganisationRole

<played by>
ORGANISATION_ENTITY: Organisation
ORGANISATION_ROLE:IdentifiableServiceDeliveryLocationRole

Specialises: :IdentifiableServiceDeliveryLocationRole

<played by>
PLACE_ENTITY: ServiceLocation
ENVIRONMENT_ROLE:SupportingOrProviderOrganisationRole

Specialises: SupportingOrProviderOrganisationRole

<played by>
ORGANISATION_ENTITY:SupportingOrProviderOrganisation
<subjectOfCare>

ENTRY.other_participants is of type PARTICIPATION

PARTICIPATION.type = SUBJ (subject of care) ** To be added **

FUNCTIONAL_ROLE_CHOICE:SubjectOfCareChoice

Specialises: OtherParticipationsChoice

PARTICIPATION:Participation

@type = SUBJ (subject of care) ** To be added **

ROLE_CHOICE:OtherRoleChoice2
<PERSON_ROLE>: Patient

Specialises: SubjectOfCareRole

@id:II = NHS Number or other unique identifier of the patient

@address(use=home) = Patient address --Structured address

@telecom = Patient telephone number(s)

<played by>
<PERSON_ENTITY>: Person

Specialises: 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

{Male, Female, Other Specific, Not Known, Not Specified}

<registered with>

ROLE_RELATIONSHIP.type = registered with

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

<PERSON_ROLE>: General Practitioner

Specialises: IdentifiablePersonInOrganisationRole

@id: II = GMC Code

<played by>
<PERSON_ENTITY>: PersonEntity

@name = GP Name -- structured/unstructured??

<is scoped by>

ROLE_RELATIONSHIP.type = is scoped by

<PERSON_ROLE>: GP Practice Role

Specialises: IdentifiableOrganisationRole

@id = GP Practice Code

@address = GP Practice address

<played by>
ORGANISATION_ENTITY: GP Practice

Specialises: OrganisationEntity

<committal>

COMPOSITION.committal is of type AUDIT_INFO

AUDIT_INFO:Audit Info

Specialises: AuditInfo

@committer:II = ** Should there be an Id of the person committing the discharge summary??***

@version_set_id: II = Document version

@version_status = VER01 (finished) ??? -- *** Useful to have this attribute to indicate whether the version of the discharge summary committed is VER00-draft, VER01 - finished, VER02 - update, VER03 - correction, VER04 - deletion

PERSON_ROLE: Committer

Specialises: IdentifiablePersonInOrganisationRole

@id:II =** Should there be an Id of the person committing the discharge summary??***

@type = Person entering data grade

@mainSpecialityCode = Person entering data Specialty -- Will a consultant ever be the committer of the discharge summary?

@treatmentFunctionCode = Person entering data Treatment Speciality -- ** To be added

<played by>
PERSON_ENTITY:Person

Specialises: PersonEntity

@name = Person entering data name

<composer>

COMPOSITION.composer is of type FUNCTIONAL_ROLE

FUNCTIONAL_ROLE_CHOICE:ComposerChoice
FUNCTIONAL_ROLE: Composer Role

Specialises: ComposerFunctionalRole

ROLE_CHOICE:ComposerRoleChoice
<composed by>
PERSON_ROLE: HCP Role

Specialises: IdentifiablePersonInOrganisationRole

@type = Person authoring data grade -- (Roles include : [0..1] Consultant, Doctor, Nurse)

@mainSpecialtyCode = Person authoring data Specialty

@clinicalTreatmentSpecialtyCode = Person authoring data Treatment Speciality -- ** To be added

<played by>
<Person Entity>: Person

Specialises: PersonEntity

@name = Person authoring data name

<attestations>

*** Add ATTESTATION_INFO to Domain Model. ***

**Add relationship type subsequently ***

COMPOSITION.attestations is of type ATTESTATION_INFO

ATTESTATION_INFO: Attestation info

Specialises: ** ATTESTATION_INFO Domain Model to be created **

@time = Discharge summary verification date -- Requires ATTESTATION_INFO domain model to meet requirement

<attester>

ATTESTATION_INFO.attester is of type FUNCTIONAL_ROLE

FUNCTIONAL_ROLE: Attester Role

** Requires Attester Functional Role Domain Model **

<played by>
PERSON_ROLE: Consultant Role

Specialises: IdentifiablePersonInOrganisationRole

@id = Consultant Code --Should the consultant id be captured for person verifying the discharge summary?

@type = Person verifying data grade

@mainSpecialtyCode = Person verifyng data Specialty

@treatmentFunctionCode = Person verifying data Treatment Speciality -- *** To be added

<played by>
PERSON_ENTITY: Person

Specialises: PersonEntity

@name = Person verifying data name