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

Contents
# Requirements Specification for Information Given To Patient And Or Authorised Representative
The verbal or written information or advice given to the patient and/or authorised representative such as relatives and carers. Differentiation is required between information given to patients, carers and any other authorised representatives. [Adapted from 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)]. Includes ‘any other relevant or necessary information (for the Patient)’. [2011/12 Standard Terms and Conditions for Acute Hospital Services (Department of Health, April 2011)].
## Recipient Name ### Business Definition The name of the person who received verbal or written information or advice. ### Requirement Reference LRA DS expert group 2011 – useful to support information governance. ### Proposed Data Values [Prefixes][Given names][Family names][Suffixes]. ### Data Use Information for patient and continuing care. ### Data Source PAS. ### Available Data Standards ISO 21090 Health informatics data types, HL7 V3 Data Types, NHS MIM data types.
## Relationship To Patient ### Business Definition The relationship of the Recipient to the patient. ### Requirement Reference LRA DS expert group 2011 – useful to support information governance. ### Proposed Data Values - Self - Carer - Spouse or civil partner - Parent or Guardian - Son or daughter - Sibling - Grandparent - Grandchild - Uncle or aunt - Nephew or Niece - Power of Attorney - Proxy; Contact - Proxy; Communication - Proxy; Contact and Communication - GP - Other health service provider - Social care service provider ### Data Use Patient information governance. ### Data Source New entry. ### Available Data Standards A potential extension of NHS Data Model & Dictionary Version 3.
## Verbal Communication Given ### Business Definition A description of information communicated verbally. ### Requirement Reference LRA DS expert group 2011 – useful to patient and for follow-up care. ### Proposed Data Values Free text. ### Data Use Follow-up care. ### Data Source New entry.
## Written Communication Given ### Business Definition A description of written communication provided. NOTE: The written information including leaflets should include local as well as national information. NOTE: All information given to patients/carers should be given in a simple understandable format without the use of acronyms and clinical jargon. ### Requirement Reference LRA DS expert group 2011 – useful to patient and for follow-up care. ### Proposed Data Values Free text. ### Data Use Follow-up care. ### Data Source New entry.