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Health records
The concepts describing how care is documented: health records, extracts, reports, and the repositories that share them.
discharge summary
discharge report summarizing a mandated period of care

Health records
The concepts describing how care is documented: health records, extracts, reports, and the repositories that share them.
- record template
  information model that is a template for recording a care record
- care data
  data produced during care activities
- care information
  information about a person relevant to their care
- care documenting
  care activity where health records are created or maintained
- health record
  data repository regarding the health and care of a subject of care
- professional health record
  health record held under the responsibility of one care provider and maintained by care professionals
- personal health record
  health record held and maintained by the subject of care or a subject of care proxy
- shareable data repository
  data repository containing health record extracts, accessible for duly authorized care actors independent of their organizational affiliation and placed under the custody of a care actor
- health record extract
  part or all of a health record extracted for the purpose of communication
- social record extract
  part or all of a social record extracted for the purpose of communication
- health report
  health record extract conveying specifically focused care information in order to fulfil current information needs of the recipient
- social care report
  social record extract conveying specifically focused social care information in order to fulfil current information needs of the recipient
- discharge report
  health report concerning a completed mandated period of care
- health summary
  electronic health record extract containing essential care information intended for specific uses
- discharge summary
  discharge report summarizing a mandated period of care
- health concern
  health record extract that includes all health record components associated with a health thread
- summarized care information repository
  data repository containing summarized information for care coordination and the continuity of care
- care communication
  care activity where two or more care actors communicate
- non-ratified care information
  care information the relevance of which has not been assessed and explicitly stated as valid by a care professional
- care information for import
  care information that is a candidate for import into a professional health record after a care professional has confirmed its clinical relevance to that professional health record
- care information request
  request sent out by a care actor to another care actor for specific care information needed for the provision of care to a subject of care
- health certificate
  official document issued by a care actor attesting to the relevant health matters of a subject of care
- health record component
  part of a health record that is identifiable for the purposes of referencing and revision
- folder
  record component used for creating hierarchical structures within an electronic health record extract and with compositions as leaf nodes
- composition
  health record component containing information composed during one clinical encounter or documentation session, and committed within one health record
- entry
  health record component that represents the data documenting one observation or a series of related observations, or a statement, an explanation of reasoning, a care intention, plan or action

discharge summary

discharge report summarizing a mandated period of care

discharge summary extends the class discharge report

Figure 1. Class Diagram

Plural discharge summaries

Example 1 “Uniform Hospital Discharge Data Set” and “Uniform Ambulatory Medical Care Minimum Data Set” in the USA.

Example 2 “Résumé de sortie standardisé” (RSS) or “Résumé d'Unité Médicale” (RUM) in France.

Example 3 Nursing minimal data set (NMDS).

Note 1 A discharge summary may be provided to the subject of care.

Note 2 One mandated period of care may be immediately followed by another; the next mandated care provider will then be a main recipient of the discharge summary.

Note 3 Discharge summaries are often meant to be processed so as to categorize hospital stays according to a statistically designed classification (such as the Diagnosis-Related Groups (DRGs) or other systems), usually for funding or epidemiological purposes.