# 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 Domain Model: Diagnosis
An ENTRY containing a collection of data items required to represent a diagnosis. Comprises a single coded Diagnosis Name and one or more Diagnosis Tags to describe the type of diagnosis (e.g. primary diagnosis, admitting diagnosis). Optionally may also contain: a textual description of the event any coded representations of findings or observations that have been interpreted to reach this diagnosis. Diagnoses can be related to other diagnoses: Diagnoses can be nested with a high level diagnosis and a series of lower level diagnoses (e.g. Diabetic Retinopathy is a complication of Diabetes Mellitus). There may also be a separate, looser relationship which specifies a relationship between the two diagnoses that does not specifically state cause (e.g. Cataract left eye is relevant to Diabetes Mellitus)2. A Diagnosis can be linked to other diagnoses that it has superseded. It may supersede the earlier Diagnoses because there is a better understanding of the condition. In this case, the earlier diagnosis was either wrong or less specific (possibly a "working" diagnosis)2. A Diagnoses can be linked to earlier Diagnoses that it has superseded because the condition has progressed from one state to another, i.e. along a clearly defined scale, or the disease has evolved with the passage of time. In this case, the earlier diagnosis was not wrong, but is now no longer valid2. Diagnoses can be related to Problems and Issues: A particular problem or issue may be related to one or many diagnoses and vice versa. A Diagnosis may be causing one or more Problems or Issues. Alternatively, the diagnosis may be made as a result of the problem being identified2. Diagnoses can be related to findings: A diagnosis may relate to one or many findings which will have been involved in the decision to make a particular diagnosis. The relationship would be: Diagnosis A is supported by Finding B; Diagnosis A is confirmed by Finding B. The inverse would be: Diagnosis A is made less likely by Finding C; Diagnosis A is ruled out by Finding D2. Diagnoses can be related to Medication Record: Where a Diagnosis leads to the prescribing of a medication, the Medication may be linked to the Diagnosis as the reason for the Medication. Normally medication would either be linked to a Problem or Issue, or to a Diagnosis, as the reason for the medication2. Incorporates requirements from the following sources: NPfIT MIM 7.2.02 Diagnosis template (COCD_TP146011UK04) Section 3.8 of NPFIT-NCR-DES-0135.07 NHS Care Record Elements Section 5.1.3 of NPFIT-FNT-TO-DPM-0931.05 SNOMED CT Bindings for Common Recording Patterns 2: NPFIT-NCR-DES-0135.07 NHS Care Record Elements ## 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
Name | ELEMENT Class | Occurs | Description
--- | --- | --- | ---
items | GenericFindingObservation | 0..* |
items | BloodPressureObservation | 0..* |
items | GenericFindingObservation2 | 0..* |
items | DiagnosisName | 1 |
items | Text | 0..* |
items | GenericTreatment | 0..* |
items | GenericPropertyObservation2 | 0..* |
items | ProductOrSubstanceRelatedActivity | 0..* |
info_provider | InformationProviderChoice | 0..1 |
items | GenericProblemAndIssue | 0..* |
subject_of_information | SubjectOfInformationChoice | 0..1 |
other_participations | OtherParticipationsChoice | 0..* |
items | GenericPropertyObservation | 0..* |
items | BodyWeightObservation | 0..* |
items | BodyHeightObservation | 0..* |
items | DiagnosisTag | 0..* |
items | TemperatureObservation | 0..* |
items | GenericProcedure | 0..* |
## ## Reference Model Type ## ENTRY