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

Contents
# Requirements Specification for Allergies And Adverse Reactions
An Allergy is an acquired hypersensitivity caused by exposure to a particular antigen (allergen) resulting in a marked increase in reactivity to that antigen upon subsequent exposure. [NPFIT-NCR-DES-0135.07 NHS Care Record Elements] It covers both propensity as well as the actual occurrence of a known or new allergy or adverse reaction. This section should include a complete list of the patient’s allergic propensities with a flag to indicate whether a listing is ‘new’ (identified during this admission). Any reactions that occurred during this admission should be described in this section. NOTE: Historical reactions data and their provenance may be held in the patient’s ongoing allergies and adverse reactions list, managed by their GP. Requirement References: - 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). - Requirement for ‘any adverse reactions or allergies to medications or treatments observed in the Patient during admission’ from) 2011/12 Standard Terms and Conditions for Acute Hospital Services (Department of Health, April 2011).
## Causative Agent ### Business Definition Agents such as food, drugs or substances that have caused or may cause an allergy or adverse reaction in this patient. ### 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). - SCG Guidance on the Representation of Allergies and Adverse Reaction Information Using NHS Message Templates (Crown Copyright, 2008). - Keeping patients safe when they transfer between care providers – getting the medicines right, Part 1: Good practice guidance for health professions, Royal Pharmaceutical Society (Final Draft 06/06/2011). ### Proposed Data Values Description of causative agent. ### Data Use Information for ongoing care, used to check / update allergy alerts in receiving systems. ### Data Source Copied from previous record. ### Data Examples - Amoxicillin - Latex - Peanuts - Floxapen - Cat dander - Alder pollen - Zinc ### Available Data Standards SNOMED CT, NHS dm+d.
## Type Of Causative Agent ### Business Definition Category of allergic propensity agent. ### Requirement Reference SCG Guidance on the Representation of Allergies and Adverse Reaction Information Using NHS Message Templates (Crown Copyright, 2008). ### Proposed Data Values - Propensity to adverse reactions to drug - Propensity to adverse reactions to food - Propensity to adverse reactions to non-drug / non-food substance ### Data Use Systems may filter based on type of propensity – e.g. GP systems may prefer to list drug propensities first / separately from other types. ### Data Source Copied from previous record entry. ### Available Data Standards SNOMED CT.
## Probability Of Causation ### Business Definition The probability that an allergic or adverse reaction may occur due to a causative agent. ### Requirement Reference - SCG Guidance on the Representation of Allergies and Adverse Reaction Information Using NHS Message Templates (Crown Copyright, 2008). - Keeping patients safe when they transfer between care providers – getting the medicines right, Part 1: Good practice guidance for health professions, Royal Pharmaceutical Society (Final Draft 06/06/2011). ### Proposed Data Values - Probably present - Suspected - Definitely present - Confirmed present ### Data Use Continuing care. ### Data Source Copied from previous record entry. ### Available Data Standards As per SCG Guidelines on Allergies and Adverse Reactions.
## New Propensity Flag ### Business Definition Indicator that this propensity is an addition to the existing list of allergic propensities. ### Requirement Reference LRA DS expert group 2011 – useful to alert GPs as an update to their patient records. ### Proposed Data Values Yes / No. ### Data Use Allows receiving systems to filter for new data to update their version of the patient’s allergic propensity list. ### Data Source Copied from previous record entry (or auto-filled at time of entry by system).
## New Reaction Description ### Business Definition A description of the manifestation of the allergic or adverse reaction experienced by the patient. The expression includes the name and may also include the severity of the allergic or adverse reaction which has occurred. NOTE: In Discharge Summary, used only for new allergic propensities (ones identified during this admission). ### Requirement Reference - NHS CFH Standards Consulting Group Guidance on the Representation of Allergies and Adverse Reaction Information Using NHS Message Templates (Crown Copyright, 2008). - Adapted from ‘Brief description of reaction’(limited here to new reaction during this hospital stay for Discharge Summaries) in Keeping patients safe when they transfer between care providers – getting the medicines right, Part 1: Good practice guidance for health professions, Royal Pharmaceutical Society (Final Draft 06/06/2011). ### Proposed Data Values Coded expression with Name, Site, Laterality and Severity. 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). - Name - Site - Laterality - Severity concepts: * Mild * Moderate * Severe ### Data Use Patient and continuing care information, allows potential update of this patient’s allergies and adverse reactions lists in receiving systems. NOTE: Severity level is clinically important as a ‘severe’ reaction may influence decisions (e.g. about future medications) even when the probability of cause is uncertain. ### Data Source Copied from previous record. ### Data Examples - Blanching rash - Allergic angioedema - Otits, external ear - Hypotension ### Available Data Standards SNOMED CT.
## Date Of Identification ### Business Definition The date the propensity was first identified or the reaction first experienced. ### Requirement Reference LRA DS expert group 2011 – clinically useful for ongoing primary care. ### Proposed Data Values A string with the format "YYYYMMDD". ### Data Use Continuing care. ### Data Source Copied from previous record 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.
## Clinical Notes ### Business Definition A textual description of the reaction as experienced by the patient. ### 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 and continuing care information. ### Data Source Copied from previous record.