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

Contents
# Requirements Specification for Medication Recommendations
A list of medications (and medications-related) recommendations advised for action following discharge. Requirement Reference: LRA DS expert group 2011.
## Medication Related Recommendation ### Business Definition A suggestion about duration and/or review, ongoing monitoring requirements, advice or starting, discontinuing or changing items in a patient’s medication record (to be actioned following discharge).Can include requirements for adherence support (e.g. compliance aids, prompts and packaging requirements). Can also include information about specific brand names or a special product where bioavailability or formulation issues arise. The recommendation may be made to another clinician or directly to the patient. It may be followed or ignored by subsequent carers. (from Medication Management in NPfIT, Version 17, 26/08/04 combined with 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). ### Requirement Reference - Medicines Reconciliation: A Guide to Implementation (National Prescribing Centre, 2008). - Medicines adherence: Involving patients in decisions about prescribed medicines and supporting adherence – NICE clinical guideline 76 (National Institute for Health and Clinical Excellence, January 2009). - 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 Free text. ### Data Use Patient information, continuing care. ### Data Source Copied from previous record entry or new entry. ### Data Examples - Patient advised to visit community pharmacist post-discharge for a medicines use review (MUR). - Consider change medication <a> to medication <b> if not effective - Consider stopping medications <c> and <d>. - Change dose of <z> after 3 weeks. - Continue medications <x> and <y>.
## Service Organisation Recommendation Recipient ### Business Definition The organisation intended as the recipient of the medication recommendation. To be used only if the intended recipient is an organisation rather than an individual. ### Requirement Reference Input received during the open review of draft LRA Discharge Summary technical models (2011). ### Proposed Data Values Organisation codes. ### Data Use Contact, information for patient and follow-up care. ### Data Source Copied from previous record or new entry. ### Available Data Standards Organisational code used within the NHS England and Wales and provided and maintained by SDS.
## Person Recommendation Recipient ### Business Definition Person who is the intended recipient for the medication recommendation. ### Requirement Reference Input received during the open review of draft LRA Discharge Summary technical models (2011). ### Proposed Data Values [Prefixes][Given names][Family names][Suffixes]. ### Data Use Contact. ### Data Source Copied from previous record entry or new record entry. ### Available Data Standards ISO 21090 Health informatics data types, HL7 V3 Data Types, NHS MIM data types.
## Contact Address ### Business Definition The address of the service. ### Requirement Reference LRA DS expert group 2011 – useful for contact. ### Proposed Data Values Address Prefix, Building Name and Building Number; Dependent Street or Road Name, and Street or Road Name; Dependent Locality and Double dependent locality; Postal Town; Postal County; Postal Code; PAF Key - unique ID for an address allocated by the Royal Mail. ### Data Use Contact. ### Data Source Copied from previous record / PAS. ### Available Data Standards BS7666 address standard, e-GIF, NHS ISB 1500: Common User Interface - Address Input and Display.
## Contact Telephone Numbers ### Business Definition Telephone number(s) associated with the service. ### Requirement Reference LRA DS expert group 2011 – useful for contact. ### 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.
## Date For Actions ### Business Definition The date(s) and optionally time when the action is planned to be executed. ### 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 A string with the format "YYYYMMDDHHMMSS.UUUU[+|-ZZzz]". ### Data Use Patient information, continuing care. ### Data Source Copied from previous record or new entry. ### 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.