# 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.
# COMPOSITION: DischargeSummary
A COMPOSITION represents the set of RECORD_COMPONENTs composed (authored) during one clinical encounter or documentation session, and committed within one EHR. ## 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. |
archetype_id | ST | 0..1 | The unique identifier of the archetype node to which this RECORD_COMPONENT corresponds, either in the EHR Provider system or as a mapping produced when this EHR_EXTRACT was created. The syntax for populating this attribute value is defined in EN 13606-2:2008. Within the LRA the value assigned to this attribute SHALL have no effect on the interpretation of instances of this class and the attribute SHALL not be used as a predicate for semantic data retrieval. |
meaning | CD.CV.SCT | 1..1 | The standardised clinical or administrative concept to which the name attribute has been mapped. In archetyped systems it will correspond to the archetype node name. In non-archetyped systems it might be a coded term from an appropriate terminology system. Within the LRA, this attribute is used by the COMPOSITION class to provide a coded representation of the type of composition, e.g. Progress note, Laboratory test result form, Radiology report, Referral letter, Clinic visit, Clinic letter, Discharge summary, etc. |
code
Semantic expression constraint
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
policy_ids | II | 0..* | This attribute identifies one or more access control policies that specifically pertain to this RECORD_COMPONENT and which need to be communicated to the EHR Recipient to govern future access to it. The identifiers may refer to policy information included in this EHR_EXTRACT as defined in EN 13606-4:2007, or to policies held in external policy servers to which the EHR Recipient has access. |
sensitivity | INT.Pos | 0..1 | The sensitivity of this RECORD_COMPONENT, represented using the code set for this attribute defined in EN 13606-4:2007. |
orig_parent_ref | II | 0..1 | The identity of the RECORD_COMPONENT that is the original parent (context) for this RECORD_COMPONENT, to be present if this information has been copied from another part of the EHR of this subject of care.. |
session_time | IVL_TS | 1..1 | The date and time or interval during which the clinical encounter or documentation session occurred. |
territory | CD.CV | 0..1 | Code for the territory in which this COMPOSITION was created, identified by ISO 3166. This will indicate the country under whose laws this COMPOSITION was created. |
contribution_id | II | 0..1 | This optional identifier may be used to logically group the set of COMPOSITIONs committed by one user at one point in time in the EHR of one subject of care, if an EHR system has permitted data to be committed simultaneously into multiple COMPOSITIONs. |
## Contained ENTRYs
Name | ENTRY Class | Occurs | Description
--- | --- | --- | ---
content | ClinicalNarrative | 0..* |
content | CareIssues | 0..* |
content | CommunityServiceActionPlan | 0..* |
content | AdmissionRelatedInformation | 0..1 |
content | RisksGoalsAndExpectations | 0..* |
content | StoppedMedicationActivity | 0..* |
content | DischargeDetails | 0..1 |
content | ProcedureActivity | 0..* |
content | Diagnosis | 0..* |
content | GPActionPlan | 0..* |
content | AllergiesOrAdverseReactionPropensity | 0..* |
content | ProvisionOfInformationAndAdvice | 0..* |
content | CurrentMedicationActivity | 0..* |
content | MedicationRecommendation | 0..* |
content | AllergiesOrAdverseReactionEvent | 0..* |
content | HospitalActionPlan | 0..* |
## Participations ### Committal Information
Name | Class | Occurs | Description
--- | --- | --- | ---
committal | CommitterAuditInfo | 1..1 | This class represents the committal and revision data about a RECORD_COMPONENT. Through the committal association from COMPOSITION this class represents the committal and revision data about this COMPOSITION in the EHR Provider system. Through the feeder_audit association from RECORD_COMPONENT this class represents the committal and revision data about this RECORD_COMPONENT in the original EHR system in which it was first committed.
### Composer
Name | Class | Occurs | Description
--- | --- | --- | ---
composer | ComposerFunctionalChoice | 1..1 | Represents a choice of FUNCTIONAL_ROLE classes used to describe the participation of a ROLE class in the COMPOSITION. The ROLE class shall participate as the composer or author of the discharge summary.
### Attestation Information
Name | Class | Occurs | Description
--- | --- | --- | ---
attestations | AttestationInfo | 1..1 | This class documents the details of any attestations that pertain to the RECORD_COMPONENTS within a COMPOSITION.
### Other Participations
Name | Class | Occurs | Description
--- | --- | --- | ---
other_participations | DistributionListFunctionalChoice | 0..1 | Represents a choice of FUNCTIONAL_ROLE classes used to describe the participation of a ROLE class in this COMPOSITION. The ROLE class shall participate as the recipient of a copy of the discharge summary.
other_participations | RecordTargetParticipationChoice | 1..1 | Represents a choice of FUNCTIONAL_ROLE classes used to describe the participation of a ROLE class in this COMPOSITION. The ROLE class shall participate as the primary target of the discharge summary record.
## ## Reference Model Type ## COMPOSITION