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

Contents
# Requirements Specification for Risks And Warnings
This is information that may be vital for a Care Professional to be made aware of quickly, concerning potential risks or warnings related to the presenting patient, or the Care Professional, or other third parties. [NPFIT-NCR-DES-0135.07 NHS Care Record Elements]. Significant risks may include the patient’s infectious disease status, any clinical alerts or risk of self-neglect, self-aggression, or exploitation by others. [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 ‘whether the Patient has any relevant infection, for example MRSA’ from the 2011/12 Standard Terms and Conditions for Acute Hospital Services (Department of Health, April 2011). NOTE: Data may appear both in this section and in other sections of the Discharge Summary (e.g. a diagnosis may be a risk and may be a ‘Diagnosis at Discharge’ or Comorbidity). Authors should be able to label a data entry in the record as a risk during a single entry process. On editing the entry, the EHR system should be able to keep risk entries in synchrony with the same data where it appears elsewhere in the record. NOTE: GPs are expected to manage the currency of data that appear on an ongoing Risks and Warnings list for the patient.
## Risk Description ### Business Definition Description of the risk to the patient or other parties. May include risk of disease/health, or self neglect/aggression/ exploitation by others, safeguarding risks (e.g. child safety concerns) and/or any clinical alerts stated as warnings. May include anaesthetic risks (e.g. difficult airway / intubation). ### 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 concept expressions. The intent is to use codes wherever applicable (to allow automated record updates and analyses), but where authors want to add free text annotation, this should also be supported. Where no appropriate code exists, this value should be free text. (Note that free text data would not be accessible to automated interpretation). ### Data Use Patient information and continuing care. ### Data Source Copied from previous record. ### Available Data Standards SNOMED CT.
## Risk Category ### Business Definition A broad indication of who is at risk. ### Requirement Reference - LRA DS expert group 2011 – useful to differentiate among individuals who may be at risk. - 2011/12 Standard Terms and Conditions for Acute Hospital Services (Department of Health, April 2011). ### Proposed Data Values - Risk to Patient - Healthcare Professional at risk - High risk of harm to others ### Data Use Patient information and continuing care. ### Data Source Copied from previous entry. ### Available Data Standards SNOMED CT.
## Risk Probability ### Business Definition The likelihood of the risk occurring to the patient and/or other parties. Note that this information is not applicable to all types of risk or warning. ### Requirement Reference LRA DS expert group 2011 – potentially clinically useful for ongoing care. ### Proposed Data Values - Definite - Possible - Probable - Equivocal ### Data Use Patient information and continuing care. ### Data Source Copied from previous record entry. ### Available Data Standards SNOMED CT.
## Other Risk Information ### Business Definition A textual description of any additional risk details. ### Requirement Reference LRA DS expert group 2011 – allowance for additional detail at the discretion of the author. ### Proposed Data Values Free text. ### Data Use Patient information and continuing care. ### Data Source Copied from previous record entry.