# 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.
# ENTRY Constrained Domain Model: CareIssues
A constrained ENTRY containing a collection of data items required to represent any issues requiring health service or carer attention, or an admission issue that represents a patient want or requirement for help. The needs or related requirements to be resolved or noted are perceived as a problem or issue by a patient, carer or a Care Professional1. Comprises a single coded Presenting Complaint and/or Problem and one or more ProblemsAndComplaints Tags to describe the type of problem (e.g. presenting complaint). Optionally may also contain: a textual description of the event any coded representations of findings, diagnosis, and procedures that have some clinical context with the generic problem or issue. any coded representation of an admission event that occurred because of the problem or presenting complaint any coded representation of a current or stopped medication activity that was initiated due to the problem or presenting complaint any coded representation of any risks, expectations or goals associated with the problem or presenting complaint. Requirements obtained from 1 LRA Discharge Summary Requirements Specification ## Specializes ## GenericProblemAndIssue ## 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): ENTRY
rc_id | II | 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. |
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. |
value
Default value: false
uncertainty_expressed | BL | 1..1 | This attribute is set to TRUE to advise the EHR Recipient that this ENTRY contains data that indicates some degree of uncertainty, and that care should be taken when using these data within automated processes and systems. |
nullFlavor
Literal value(s): NA
## Contained ELEMENTs ## Graphical Representation
Subject ELEMENT class | Related object classes
--- | ---
Name | ELEMENT Class | Occurs | Description | Relationship | Occurs | Class | Dependency
items | Diagnosis | 0 .. * |  | IsComplicatedBy | 0..* | Diagnosis ProcedureActivity | INDEPENDENT
IsClinicalContextOf | 0..* | CareIssues | INDEPENDENT
IsIndicationOf | 0..* | CurrentMedicationActivity StoppedMedicationActivity | INDEPENDENT
HasRecordRole | 0..1 | DiagnosisStatus | INDEPENDENT
HasAnnotation | 0..* | Text | INDEPENDENT
items | Text | 0 .. * |  |  |  |  |
items | ProcedureActivity | 0 .. * |  | IsComplicatedBy | 0..* | ProcedureActivity FindingObservation | INDEPENDENT
HasIndication | 0..* | Diagnosis FindingObservation CareIssues | INDEPENDENT
IsIndicationOf | 0..* | StoppedMedicationActivity CurrentMedicationActivity | INDEPENDENT
HasAnnotation | 0..* | Text | INDEPENDENT
Complicates | 0..* | Diagnosis | INDEPENDENT
items | CurrentMedicationActivity | 0 .. * |  | HasTemporalContext | 0..* | MedicationFutureCourseTiming MedicationCourseTiming | INDEPENDENT
HasRecordRole | 0..* | CurrentMedicationReconciliationStatus | INDEPENDENT
HasTemporalContext | 0..* | CurrentMedicationActivity | INDEPENDENT
HasParameterSetting | 0..* | DoseQuantity | INDEPENDENT
AssertsTiming | 0..* | EventDoseFrequency MeasuredDoseFrequency MedicationReviewText | INDEPENDENT
Consumes | 1..* | MedicinalProductOrSubstance | INDEPENDENT
HasAnnotation | 0..* | DosageInstructions | INDEPENDENT
UsesDevice | 0..* | MedicinalDevice ComplianceDevice | INDEPENDENT
IsProspectOf | 1..* | MedicationRecommendationActivity | INDEPENDENT
IsPrecedentOf | 1..* | StoppedMedicationActivity | INDEPENDENT
HasAnnotation | 0..* | DosageInstructions AdditionalInstructions | INDEPENDENT
HasIndication | 0..* | AllergiesOrAdverseReactionEvent TreatmentActivity InvestigationActivity FindingObservation CurrentMedicationActivity ReasonForMedicationText PropertyObservation ProcedureActivity CareIssues Diagnosis | INDEPENDENT
IsComponentActionOf | 0..* | CurrentMedicationActivity TreatmentActivity | INDEPENDENT
HasComponentAction | 0..* | MedicationReviewActivity | INDEPENDENT
items | CareIssues | 1 |  | IsClinicalContextOf | 0..* | AdmissionEvent | INDEPENDENT
HasRecordRole | 0..* | ProblemsAndComplaintsTag | INDEPENDENT
HasClinicalContext | 0..* | ProcedureActivity Diagnosis FindingObservation | INDEPENDENT
IsIndicationOf | 0..* | StoppedMedicationActivity CurrentMedicationActivity | INDEPENDENT
IsMotivationOf | 0..* | ProcedureActivity AdmissionEvent | INDEPENDENT
HasAnnotation | 0..* | Text | INDEPENDENT
items | ProblemsAndComplaintsTag | 0 .. * |  |  |  |  |
items | StoppedMedicationActivity | 0 .. * |  | HasRecordRole | 0..* | StoppedMedicationReconciliationStatus | INDEPENDENT
HasAnnotation | 0..* | Text | INDEPENDENT
HasTemporalContext | 0..* | StoppedMedicationActivity | INDEPENDENT
IsComponentActionOf | 0..* | StoppedMedicationActivity TreatmentActivity | INDEPENDENT
HasPredecessor | 1..* | CurrentMedicationActivity | INDEPENDENT
HasIndication | 0..* | ReasonForStoppingMedicationText ProcedureActivity FindingObservation PropertyObservation AllergiesOrAdverseReactionEvent StoppedMedicationActivity InvestigationActivity Diagnosis CareIssues TreatmentActivity | INDEPENDENT
items | AdmissionEvent | 0 .. * |  | HasClinicalContext | 0..* | CareIssues | INDEPENDENT
HasContext | 0..1 | AdmissionMethod | DEPENDENT_OBJECT
HasAnnotation | 0..* | Text | INDEPENDENT
HasMotivation | 0..* | CareIssues ProcedureActivity AllergiesOrAdverseReactionEvent RiskGoalsAndExpectations | INDEPENDENT
items | FindingObservation | 0 .. * |  | IsClinicalContextOf | 0..* | CareIssues | INDEPENDENT
IsIndicationOf | 0..* | StoppedMedicationActivity CurrentMedicationActivity ProcedureActivity | INDEPENDENT
HasAnnotation | 0..* | Text | INDEPENDENT
## Participations ### Other Participations
Name | Class | Occurs | Description
--- | --- | --- | ---
other_participations | ProblemAndComplaintResponsibilityChoice | 1..1 | Represents a choice of FUNCTIONAL_ROLE classes used to describe the participation of a ROLE class in a COMPOSITION or an ENTRY. The ROLE class shall participate as a non-specific 'other participation' representing the person who is responsible for recording the problem about the subject of care.
## Content of COMPOSITION Models ### DischargeSummary ## Reference Model Type ## ENTRY