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

Contents
# Requirements Specification for Hospital Advice Recommendations And Future Plan
Actions required/that will be carried out by the hospital department. To include: - Action (e.g. outpatient, pending investigations and results, outstanding issues) - Person responsible - Appropriate date and time. [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 planned follow-up arrangements’ (2011/12 Standard Terms and Conditions for Acute Hospital Services (Department of Health, April 2011)).
## Hospital Actions ### Business Definition Actions required to be taken up by the hospital post discharge of the patient e.g. Outpatient activities, planned investigations, and other outstanding issues). ### Requirement Reference 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). ### Proposed Data Values Coded value (free text as exception). ### Data Use Patient information and continuing care. ### Data Source Copied from previous record (e.g. procedure waiting list, investigations planned, planned clinic appointments) or manual entry where necessary.
## Contact Person ### Business Definition The person, in the capacity of the role they play in the hospital, responsible for performing the action. ### Requirement Reference 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). ### Proposed Data Values [Prefixes][Given names][Family names][Suffixes]. ### Data Use Future communication. ### Data Source Copied from previous record or new record entry. ### Available Data Standards ISO 21090 Health informatics data types, HL7 V3 Data Types, NHS MIM data types.
## Specialty Department Responsible For Action ### Business Definition The speciality/department responsible for action. ### Requirement Reference 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). ### Proposed Data Values The list of Specialty codes defined by the National Workforce Data set (NWD) v2.2 approved by the NHS Information Centre. ### Data Use Patient information, continuing care. ### Data Source Copied from previous record or new entry.
## Date For Actions ### Business Definition The date and optionally time when the action is planned to be executed by the hospital. ### Requirement Reference 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). ### Proposed Data Values A string with the format "YYYYMMDDHHMMSS.UUUU[+|-ZZzz]". ### Data Use Patient information, continuing care. ### Data Source Copied from previous record entry or new entry. ### Available Data Standards ISO 11404 - Point in Time, NHS ISB 1502: Common User Interface - Date and Time Input, NHS ISB 1503: Common User Interface - Date Display, NHS ISB 1501: Common User Interface - Time Display.
## Comments ### Business Definition Opportunity to record additional information about the future action. May include the status of the action in terms of Booked, Proposed or Requested. ### Requirement Reference LRA DS expert group 2011 – potentially useful for added detail at the author's discretion. ### Proposed Data Values Free text. ### Data Use Patient information, continuing care. ### Data Source Copied from previous record entry or new entry.