# 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.
# ELEMENT Domain Model: DiagnosisTag
An ELEMENT to represent a Diagnosis Tag. A Diagnosis Tag is used to tag a diagnosis with a particular status. It represents the administrative or process-related type of the associated diagnosis (e.g. primary diagnosis, admission diagnosis, etc), but not the clinical condition diagnosed5. The Diagnosis Tag is intended to be used to answer questions that relate to the interface between the clinical and administrative processes. For example, to identify the primary and secondary diagnoses for statistical analysis5. Each instance of a Diagnosis Tag represents a single type of administrative or process-related category in a specific scope. For example, there is a separate instance of Diagnosis Tag for the primary diagnosis for each hospital stay5. The scope of a Diagnosis Tag is indicated by its relationship with other record components. For example, the Diagnosis Tag representing the primary discharge diagnosis of a hospital stay is linked to a component representing that hospital stay5. Some Diagnosis Tags represent categories which only have one value in each scope. For example, the 'primary diagnosis' for a single hospital stay. In these cases, each instance of a Diagnosis Tag may only be linked to one Diagnosis Name. The primary diagnosis of each subsequent hospital stay is represented by another Diagnosis Tag and linked to an appropriate Diagnosis Name5. Some Diagnosis Tag represent categories which may have multiple values in a single scope. For example, there may be several 'secondary diagnoses'; and a 'differential diagnosis' is inherently a collection of multiple options. In these cases, each instance of a Diagnosis Tag may be linked to several Diagnosis Name. However, even in these cases, a separate Diagnosis Tag is required for each similar collection in a different scope (e.g. for a subsequent hospital stay)5. Where appropriate, the same clinical finding can be linked to several Diagnosis Tags. For example, if the same condition is the primary diagnosis of more than one hospital stay5. The Diagnosis Tag does not affect the clinical interpretation of the Diagnosis Name. For example, if a Diagnosis Tag of 'differential diagnosis' was used, the uncertainty ascribed to the diagnosis must also be represented explicitly, using the relevant context attributes in the Diagnosis Name5. Changes to the diagnosis ascribed to a particular category are represented by creating links between a Diagnosis Tag and a different Diagnosis Name and marking the existing links as invalid5. Progress of a Diagnosis Name (e.g. from an admission diagnosis to a primary discharge diagnosis) is represented by creating a new link to the appropriate Diagnosis Tag5. 5: NPFIT-FNT-TO-DPM-0931.05 SNOMED CT Bindings for Common Recording Patterns ## 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): RECORD_ARTEFACT_ELEMENT
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. |
meaning | CD.CV.SCT | 1..1 | A coded representation of the type of diagnosis (e.g. primary diagnosis, admitting diagnosis). |
code
Semantic expression constraint
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
obs_time | IVL_TS | 0..1 | The date and time, or interval, at which the Diagnosis Tag is applicable. |
value | ANY | 1..1 | An ELEMENT has a single DATA_VALUE containing the value, unless this is indicated as absent by a null_flavour attribute. |
nullFlavor
Literal value(s): NA
## COMPONENT RELATIONSHIPS ### Object of relationships
Name | Subject of relationship | Occurs | Dependency
--- | --- | --- | ---
HasRecordRole | DiagnosisName | 0..* | DEPENDENT_OBJECT
## Item of ENTRY Domain Models ### Diagnosis ## Reference Model Type ## RECORD_ARTEFACT_ELEMENT