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

Contents
# Requirements Specification for Advance Decisions And Resuscitation Status
Advance Decisions to Refuse Treatment (ADRT) are written documents, completed and signed when a person is legally competent, that explain a person’s medical wishes in advance, allowing someone else to make treatment decisions on his or her behalf later in the disease process. Includes Do Not Resuscitate orders. 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).
## Advance Decisions To Refuse Treatment ### Business Definition Description of any advance decision to refuse treatment, including with respect to resuscitation. NOTE: The ADRT documentation states that if a person becomes mentally incapable of making decisions later on in life then the ADRT document written and signed by the patient when they were mentally well should be taken into account. ### 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 Free text. ### Data Use Ongoing care. ### Data Source Copied from previous record entry.
## Link To ADRT Document ### Business Definition Link to a copy of the Advanced Decisions to Refuse Treatment document, completed and signed by the person indicating the ADRT. This document will include the person to be contacted to discuss the wishes of the patient. ### Requirement Reference LRA DS expert group 2011 – potentially useful, when a formal document exists. ### Proposed Data Values Free text link to an Advanced Decision to Refuse Treatment document. ### Data Use Ongoing care. ### Data Source Copied from previous record entry.