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

Contents
# Requirements Specification for GP Advice Recommendations And Future Plan
Actions advised or recommended to the GP. To include: - Action (e.g. specific actions, pending investigations and results, outstanding issues, HRT and cervical screening). - Person responsible - Appropriate date and time - Suggested strategies for potential problems, e.g. telephone contact for advice [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 immediate post-discharge requirement from the primary healthcare team’ (2011/12 Standard Terms and Conditions for Acute Hospital Services (Department of Health, April 2011)).
## GP Actions ### Business Definition Action suggestions directed to the GP by the hospital at the time of discharge of the patient. These may include a clinical review to be performed (e.g. BP check, investigations, etc), a prescribing review (based on medication recommendations and discharge medications prescribed), vaccination, referral to another service, strategies for potential problems, etc. ### 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). - 2011/12 Standard Terms and Conditions for Acute Hospital Services (Department of Health, April 2011). ### Proposed Data Values Coded value (free text as exception). ### Data Use Patient information and continuing care. ### Data Source Copied from previous record or new entry.
## Date For Actions ### Business Definition The date(s) and optionally time when the action is planned to be executed. ### 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 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 or new entry.