The codes identify the conditions under which accept acknowledgements are required to be returned in response to this message. Note that accept acknowledgement address two different issues at the same time: reliable transport as well as syntactical correctness
Send an acknowledgement for error/reject conditions only.
Send an acknowledgement for successful completions only.
Refelects rejections because elements of the communication are not supported in the current context.
Reflects errors in the syntax or structure of the communication.
An internal software component (database, application, queue mechanism, etc.) has failed, leading to inability to process the message.
Rejection: The message can't be stored by the receiver due to an unspecified internal application issue. The message was neither processed nor stored by the receiving application.
Error: The destination of this message is known to the receiving application. Messages have been successfully routed to that destination in the past. The link to the destination application or an intermediate application is unavailable.
The destination of this message is unknown to the receiving application. The receiving application in the message does not match the application which received the message. The message was neither routed, processed nor stored by the receiving application.
Warning: The destination of this message is known to the receiving application. Messages have been successfully routed to that destination in the past. The link to the destination application or an intermediate application is (temporarily) unavailable. The receiving application will forward the message as soon as the destination can be reached again.
The interaction (or: this version of the interaction) is not supported.
The receiver requires information in the attentionLine classes for routing purposes.
Required association missing in message; or the sequence of the classes is different than required by the standard or one of the conformance profiles identified in the message.
A required attribute is missing in a class.
The attribute contained data of the wrong data type, e.g. a numeric attribute contained "FOO".
An attribute value was compared against the corresponding code system, and no match was found.
An attribute value referenced a code system that is not valid for an attribute constrained to CNE.
The number of repetitions of a (group of) association(s) exceeds the limits of the standard or of one of the conformance profiles identified in the message.
The number of repetitions of an attribute exceeds the limits of the standard or of one of the conformance profiles identified in the message.
A record of something that is being done, has been done, can be done, or is intended or requested to be done. Examples:The kinds of acts that are common in health care are (1) a clinical observation, (2) an assessment of health condition (such as problems and diagnoses), (3) healthcare goals, (4) treatment services (such as medication, surgery, physical and psychological therapy), (5) assisting, monitoring or attending, (6) training and education services to patients and their next of kin, (7) and notary services (such as advanced directives or living will), (8) editing and maintaining documents, and many others. Discussion and Rationale: Acts are the pivot of the RIM; all domain information and processes are represented primarily in Acts. Any profession or business, including healthcare, is primarily constituted of intentional and occasionally non-intentional actions, performed and recorded by responsible actors. An Act-instance is a record of such an action. Acts connect to Entities in their Roles through Participations and connect to other Acts through ActRelationships. Participations are the authors, performers and other responsible parties as well as subjects and beneficiaries (which includes tools and material used in the performance of the act, which are also subjects). The moodCode distinguishes between Acts that are meant as factual records, vs. records of intended or ordered services, and the other modalities in which act can appear. One of the Participations that all acts have (at least implicitly) is a primary author, who is responsible of the Act and who "owns" the act. Responsibility for the act means responsibility for what is being stated in the Act and as what it is stated. Ownership of the act is assumed in the sense of who may operationally modify the same act. Ownership and responsibility of the Act is not the same as ownership or responsibility of what the Act-object refers to in the real world. The same real world activity can be described by two people, each being the author of their Act, describing the same real world activity. Yet one can be a witness while the other can be a principal performer. The performer has responsibilities for the physical actions; the witness only has responsibility for making a true statement to the best of his or her ability. The two Act-instances may even disagree, but because each is properly attributed to its author, such disagreements can exist side by side and left to arbitration by a recipient of these Act-instances. In this sense, an Act-instance represents a "statement" according to Rector and Nowlan (1991) [Foundations for an electronic medical record. Methods Inf Med. 30.] Rector and Nowlan have emphasized the importance of understanding the medical record not as a collection of facts, but "a faithful record of what clinicians have heard, seen, thought, and done." Rector and Nowlan go on saying that "the other requirements for a medical record, e.g., that it be attributable and permanent, follow naturally from this view." Indeed the Act class is this attributable statement, and the rules of updating acts (discussed in the state-transition model, see Act.statusCode) versus generating new Act-instances are designed according to this principle of permanent attributable statements. Rector and Nolan focus on the electronic medical record as a collection of statements, while attributed statements, these are still mostly factual statements. However, the Act class goes beyond this limitation to attributed factual statements, representing what is known as "speech-acts" in linguistics and philosophy. The notion of speech-act includes that there is pragmatic meaning in language utterances, aside from just factual statements; and that these utterances interact with the real world to change the state of affairs, even directly cause physical activities to happen. For example, an order is a speech act that (provided it is issued adequately) will cause the ordered action to be physically performed. The speech act theory has culminated in the seminal work by Austin (1962) [How to do things with words. Oxford University Press]. An activity in the real world may progress from defined, through planned and ordered to executed, which is represented as the mood of the Act. Even though one might think of a single activity as progressing from planned to executed, this progression is reflected by multiple Act-instances, each having one and only one mood that will not change along the Act-instance life cycle. This is because the attribution and content of speech acts along this progression of an activity may be different, and it is often critical that a permanent and faithful record be maintained of this progression. The specification of orders or promises or plans must not be overwritten by the specification of what was actually done, so as to allow comparing actions with their earlier specifications. Act-instances that describe this progression of the same real world activity are linked through the ActRelationships (of the relationship category "sequel"). Act as statements or speech-acts are the only representation of real world facts or processes in the HL7 RIM. The truth about the real world is constructed through a combination (and arbitration) of such attributed statements only, and there is no class in the RIM whose objects represent "objective state of affairs" or "real processes" independent from attributed statements. As such, there is no distinction between an activity and its documentation. Every Act includes both to varying degrees. For example, a factual statement made about recent (but past) activities, authored (and signed) by the performer of such activities, is commonly known as a procedure report or original documentation (e.g., surgical procedure report, clinic note etc.). Conversely, a status update on an activity that is presently in progress, authored by the performer (or a close observer) is considered to capture that activity (and is later superceded by a full procedure report). However, both status update and procedure report are acts of the same kind, only distinguished by mood and state (see statusCode) and completeness of the information.
A context representing a grouped commitment of information to the EHR. It is considered the unit of modification of the record, the unit of transmission in record extracts, and the unit of attestation by authorizing clinicians. A composition represents part of a patient record originating from a single interaction between an authenticator and the record. Unless otherwise stated all statements within a composition have the same authenticator, apply to the same patient and were recorded in a single session of use of a single application. A composition contains organizers and entries.
This context represents the information acquired and recorded for an observation, a clinical statement such as a portion of the patient's history or an inference or assertion, or an action that might be intended or has actually been performed. This class may represent both the actual data describing the observation, inference, or action, and optionally the details supporting the clinical reasoning process such as a reference to an electronic guideline, decision support system, or other knowledge reference.
This context represents the part of a patient record conveyed in a single communication. It is drawn from a providing system for the purposes of communication to a requesting process (which might be another repository, a client application or a middleware service such as an electronic guideline engine), and supporting the faithful inclusion of the communicated data in the receiving system. An extract may be the entirety of the patient record as held by the sender or it may be a part of that record (e.g. changes since a specified date). An extract contains folders or compositions. An extract cannot contain another extract.
A context representing the high-level organization of an extract e.g. to group parts of the record by episode, care team, clinical specialty, clinical condition, or source application. Internationally, this kind of organizing structure is used variably: in some centers and systems the folder is treated as an informal compartmentalization of the overall health record; in others it might represent a significant legal portion of the EHR relating to the originating enterprise or team. A folder contains compositions. Folders may be nested within folders.
Organizer of entries. Navigational. No semantic content. Knowledge of the section code is not required to interpret contained observations. Represents a heading in a heading structure, or "organizer tree". The record entries relating to a single clinical session are usually grouped under headings that represent phases of the encounter, or assist with layout and navigation. Clinical headings usually reflect the clinical workflow during a care session, and might also reflect the main author's reasoning processes. Much research has demonstrated that headings are used differently by different professional groups and specialties, and that headings are not used consistently enough to support safe automatic processing of the E H R.
A Region of Interest (ROI) specified for a multidimensional observation, such as an Observation Series (OBSSER). The ROI is specified using a set of observation criteria, each delineating the boundary of the region in one of the dimensions in the multidimensional observation. The relationship between a ROI and its referenced Act is specified through an ActRelationship of type subject (SUBJ), which must always be present. Each of the boundary criteria observations is connected with the ROI using ActRelationships of type "has component" (COMP). In each boundary criterion, the Act.code names the dimension and the Observation.value specifies the range of values inside the region. Typically the bounded dimension is continuous, and so the Observation.value will be an interval (IVL) data type. The Observation.value need not be specified if the respective dimension is only named but not constrained. For example, an ROI for the QT interval of a certain beat in ECG Lead II would contain 2 boundary criteria, one naming the interval in time (constrained), and the other naming the interval in ECG Lead II (only named, but not constrained).
A Region of Interest (ROI) specified for an image using an overlay shape. Typically used to make reference to specific regions in images, e.g., to specify the location of a radiologic finding in an image or to specify the site of a physical finding by "circling" a region in a schematic picture of a human body. The units of the coordinate values are in pixels. The origin is in the upper left hand corner, with positive X values going to the right and positive Y values going down. The relationship between a ROI and its referenced Act is specified through an ActRelationship of type "subject" (SUBJ), which must always be present.
Lying with the front or ventral surface downward; lying face down.
A semi-sitting position in bed with the head of the bed elevated approximately 45 degrees.
Resting the body on the buttocks, typically with upper torso erect or semi erect.
To be stationary, upright, vertical, on oneaTMs legs.
A code specifying qualitatively the spatial relation between imaged object and imaging film or detector.
Contains codes for defining the observed, physical position of a subject, such as during an observation, assessment, collection of a specimen, etc. ECG waveforms and vital signs, such as blood pressure, are two examples where a general, observed position typically needs to be noted.
An accommodation is a service provided for a Person or other LivingSubject in which a place is provided for the subject to reside for a period of time. Commonly used to track the provision of ward, private and semi-private accommodations for a patient.
A financial account established to track the net result of financial acts.
A unit of work, a grouper of work items as defined by the system performing that work. Typically some laboratory order fulfillers communicate references to accessions in their communications regarding laboratory orders. Often one or more specimens are related to an accession such that in some environments the accession number is taken as an identifier for a specimen (group).
A transformation process where a requested invoice is transformed into an agreed invoice. Represents the adjudication processing of an invoice (claim). Adjudication results can be adjudicated as submitted, with adjustments or refused. Adjudication results comprise 2 components: the adjudication processing results and a restated (or adjudicated) invoice or claim
An act representing a system action such as the change of state of another act or the initiation of a query. All control acts represent trigger events in the HL7 context. ControlActs may occur in different moods.
An agreement of obligation between two or more parties that is subject to contractual law and enforcement.
The Consent class represents informed consents and all similar medico-legal transactions between the patient (or his legal guardian) and the provider. Examples are informed consent for surgical procedures, informed consent for clinical trials, advanced beneficiary notice, against medical advice decline from service, release of information agreement, etc. The details of consents vary. Often an institution has a number of different consent forms for various purposes, including reminding the physician about the topics to mention. Such forms also include patient education material. In electronic medical record communication, consents thus are information-generating acts on their own and need to be managed similar to medical activities. Thus, Consent is modeled as a special class of Act. The "signatures" to the consent document are represented electronically through Participation instances to the consent object. Typically an informed consent has Participation.typeCode of "performer", the healthcare provider informing the patient, and "consenter", the patient or legal guardian. Some consent may associate a witness or a notary public (e.g., living wills, advanced directives). In consents where a healthcare provider is not required (e.g. living will), the performer may be the patient himself or a notary public. Some consent has a minimum required delay between the consent and the service, so as to allow the patient to rethink his decisions. This minimum delay can be expressed in the act definition by the ActRelationship.pauseQuantity attribute that delays the service until the pause time has elapsed after the consent has been completed.
An Act where a container is registered either via an automated sensor, such as a barcode reader, or by manual receipt
An identified point during a clinical trial at which one or more actions are scheduled to be performed (definition mood), or are actually performed (event mood). The actions may or may not involve an encounter between the subject and a healthcare professional.
An action taken with respect to a subject Entity by a regulatory or authoritative body with supervisory capacity over that entity. The action is taken in response to behavior by the subject Entity that body finds to be undesirable. Suspension, license restrictions, monetary fine, letter of reprimand, mandated training, mandated supervision, etc.Examples:
The action of coming into sufficient physical proximity to allow physical or chemical interaction. Examples include: exposure to radiation, inhalation of peanut aerosol or viral particles. This includes intended exposure (e.g. administering a drug product) as well as accidental or environmental exposure. Actual vs. potential exposure can be differentiated using Act.uncertaintyCode. The agent to which the subject was exposed is conveyed as a Direct participation or specialization there-of. Constraints: The following Participations should be used with the following Roles and Entities to distinguish the specific entities: The exposed entity is the entity of interest that is the recipient of the exposure and potentially affected. This is conveyed through the subject (SBJ) Participation. An entity that has carried the agent transmitted in the exposure is the " exposure source " (EXSRC). For example: a person or animal who carried an infectious disease and interacts (EXSRC) with another person or animal (SBJ) transmitting the disease agent; or a place or other environment (EXSRC) and a person or animal (SBJ) who is exposed in the presence of this environment. When it is unknown whether a participating entity is the source of the agent (EXSRC) or the target of the transmission (SBJ), also known as " exposure contact ", the "participant" (PART) is used. The substance to which the subject is exposed that carries the exposure agent or the chemical substance of interest itself, participates as a "consumable" (CSM). There are at least two configurations: (a) the player of the Role that participates as CSM is the chemical or biological substance mixed or carried by the scoper-entity of the Role (e.g., ingredient role); or (b) the player of the Role that participates as CSM is a mixture known to contain the chemical, radiological or biological substance of interest. The device specifically used to administer the substance is associated using the device (DEV) Participation. This may be a device intentionally used (such as applicator device) or it may be a thing that accidentally carried this substance; for instance, an infected needle or knife. The same entity may be related in the act as both EXSRC and DEV.
An event that occurred outside of the control of one or more of the parties involved. Includes the concept of an accident.
The act of transmitting information and understanding about a topic to a subject where the participation association must be SBJ. Discussion: This act may be used to request that a patient or provider be informed about an Act, or to indicate that a person was informed about a particular act.
Represents concepts related to invoice processing in health care
Working list collects a dynamic list of individual instances of Act via ActRelationship which reflects the need of an individual worker, team of workers, or an organization to manage lists of acts for many different clinical and administrative reasons. Examples of working lists include problem lists, goal lists, allergy lists, and to-do lists.
An officially or unofficially instituted program to track acts of a particular type or categorization.
Description:An act that is intended to result in new information about a subject. The main difference between Observations and other Acts is that Observations have a value attribute. The code attribute of Observation and the value attribute of Observation must be considered in combination to determine the semantics of the observation. Discussion: Structurally, many observations are name-value-pairs, where the Observation.code (inherited from Act) is the name and the Observation.value is the value of the property. Such a construct is also known as a variable (a named feature that can assume a value) hence, the Observation class is always used to hold generic name-value-pairs or variables, even though the variable valuation may not be the result of an elaborate observation method. It may be a simple answer to a question or it may be an assertion or setting of a parameter. As with all Act statements, Observation statements describe what was done, and in the case of Observations, this includes a description of what was actually observed (results or answers); and those results or answers are part of the observation and not split off into other objects. The method of action is asserted by the Observation classCode or its subclasses at the least granular level, by the Observation.code attribute value at the medium level of granularity, and by the attribute value of observation.methodCode when a finer level of granularity is required. The method in whole or in part may also appear in the attribute value of Observation.value when using coded data types to express the value of the attribute. Relevant aspects of methodology may also be restated in value when the results themselves imply or state a methodology. An observation may consist of component observations each having their own Observation.code and Observation.value. In this case, the composite observation may not have an Observation.value for itself. For instance, a white blood cell count consists of the sub-observations for the counts of the various granulocytes, lymphocytes and other normal or abnormal blood cells (e.g., blasts). The overall white blood cell count Observation itself may therefore not have a value by itself (even though it could have one, e.g., the sum total of white blood cells). Thus, as long as an Act is essentially an Act of recognizing and noting information about a subject, it is an Observation, regardless of whether it has a simple value by itself or whether it has sub-observations. Even though observations are professional acts (see Act) and as such are intentional actions, this does not require that every possible outcome of an observation be pondered in advance of it being actually made. For instance, differential white blood cell counts (WBC) rarely show blasts, but if they do, this is part of the WBC observation even though blasts might not be predefined in the structure of a normal WBC. Clinical documents commonly have Subjective and Objective findings, both of which are kinds of Observations. In addition, clinical documents commonly contain Assessments, which are also kinds of Observations. Thus, the establishment of a diagnosis is an Observation. Examples: Recording the results of a Family History Assessment Laboratory test and associated result Physical exam test and associated result Device temperature Soil lead level
An Act that of taking on whole or partial responsibility for, or attention to, safety and well-being of a subject of care. Discussion: A care provision event may exist without any other care actions taking place. For example, when a patient is assigned to the care of a particular health professional. In request (RQO) mood care provision communicates a referral, which is a request: from one party (linked as a participant of type author (AUT)), to another party (linked as a participant of type performer (PRF), to take responsibility for a scope specified by the code attribute, for an entity (linked as a participant of type subject (SBJ)). The scope of the care for which responsibility is taken is identified by code attribute. In event (EVN) mood care provision indicates the effective time interval of a specified scope of responsibility by a performer (PRF) or set of performers (PRF) for a subject (SBJ). Examples: Referral from GP to a specialist. Assignment of a patient or group of patients to the case list of a health professional. Assignment of inpatients to the care of particular nurses for a working shift.
Description:A mandate, regulation, obligation, requirement, rule, or expectation unilaterally imposed by one party on: The activity of another party The behavior of another party The manner in which an act is executed
Represents the act of maintaining information about the registration of its associated registered subject. The subject can be either an Act or a Role, and includes subjects such as lab exam definitions, drug protocol definitions, prescriptions, persons, patients, practitioners, and equipment. The registration may have a unique identifier - separate from the unique identification of the subject - as well as a core set of related participations and act relationships that characterize the registration event and aid in the disposition of the subject information by a receiving system.Usage notes:
The act of examining and evaluating the subject, usually another act. For example, "This prescription needs to be reviewed in 2 months."
The act of introducing or otherwise applying a substance to the subject. Discussion: The effect of the substance is typically established on a biochemical basis, however, that is not a requirement. For example, radiotherapy can largely be described in the same way, especially if it is a systemic therapy such as radio-iodine. This class also includes the application of chemical treatments to an area. Examples: Chemotherapy protocol; Drug prescription; Vaccination record
A procedure or treatment performed on a specimen to prepare it for analysis
Supply orders and deliveries are simple Acts that focus on the delivered product. The product is associated with the Supply Act via Participation.typeCode="product". With general Supply Acts, the precise identification of the Material (manufacturer, serial numbers, etc.) is important. Most of the detailed information about the Supply should be represented using the Material class. If delivery needs to be scheduled, tracked, and billed separately, one can associate a Transportation Act with the Supply Act. Pharmacy dispense services are represented as Supply Acts, associated with a SubstanceAdministration Act. The SubstanceAdministration class represents the administration of medication, while dispensing is supply.
Definition: Indicates that the subject Act has undergone or should undergo substitution of a type indicated by Act.code. Rationale: Used to specify "allowed" substitution when creating orders, "actual" susbstitution when sending events, as well as the reason for the substitution and who was responsible for it.
Definition: The act of transferring information without the intent of imparting understanding about a topic to the subject that is the recipient or holder of the transferred information where the participation association must be RCV or HLD.
Transportation is the moving of a payload (people or material) from a location of origin to a destination location. Thus, any transport service has the three target instances of type payload, origin, and destination, besides the targets that are generally used for any service (i.e., performer, device, etc.)
A sub-class of Act representing any transaction between two accounts whose value is measured in monetary terms. In the "intent" mood, communicates a request for a transaction to be initiated, or communicates a transfer of value between two accounts. In the "event" mood, communicates the posting of a transaction to an account.
Sender asks addressee to do something depending on the focal Act of the payload. An example is "fulfill this order". Addressee has responsibilities to either reject the message or to act on it in an appropriate way (specified by the specific receiver responsibilities for the interaction).
Sender sends payload to addressee as information. Addressee does not have responsibilities beyond serving addressee's own interest (i.e., read and memorize if you see fit). This is equivalent to an FYI on a memo.
Sender transmits a status change pertaining to the focal act of the payload. This status of the focal act is the final state of the state transition. This can be either a request or a command, according to the mood of the control act.
An outbreak represents a series of public health cases. The date on which an outbreak starts is the earliest date of onset among the cases assigned to the outbreak, and its ending date is the last date of onset among the cases assigned to the outbreak.
A contract whose value is measured in monetary terms.
The notion of a document comes particularly from the paper world, where it corresponds to the contents recorded on discrete pieces of paper. In the electronic world, a document is a kind of composition that bears resemblance to their paper world counter-parts. Documents typically are meant to be human-readable. HL7's notion of document differs from that described in the W3C XML Recommendation, in which a document refers specifically to the contents that fall between the root element's start-tag and end-tag. Not all XML documents are HL7 documents.
A public health case is an Observation representing a condition or event that has a specific significance for public health. Typically it involves an instance or instances of a reportable infectious disease or other condition. The public health case can include a health-related event concerning a single individual or it may refer to multiple health-related events that are occurrences of the same disease or condition of interest to public health. An outbreak involving multiple individuals may be considered as a type of public health case. A public health case definition (Act.moodCode = "definition") includes the description of the clinical, laboratory, and epidemiologic indicators associated with a disease or condition of interest to public health. There are case definitions for conditions that are reportable, as well as for those that are not. There are also case definitions for outbreaks. A public health case definition is a construct used by public health for the purpose of counting cases, and should not be used as clinical indications for treatment. Examples include AIDS, toxic-shock syndrome, and salmonellosis and their associated indicators that are used to define a case.
A clinical document is a documentation of clinical observations and services, with the following characteristics: Persistence - A clinical document continues to exist in an unaltered state, for a time period defined by local and regulatory requirements; Stewardship - A clinical document is maintained by a person or organization entrusted with its care; Potential for authentication - A clinical document is an assemblage of information that is intended to be legally authenticated; Wholeness - Authentication of a clinical document applies to the whole and does not apply to portions of the document without the full context of the document; Human readability - A clinical document is human readable.
A clinical document that conforms to Level One of the HL7 Clinical Document Architecture (CDA)
Description:A battery specifies a set of observations. These observations typically have a logical or practical grouping for generally accepted clinical or functional purposes, such as observations that are run together because of automation. A battery can define required and optional components and, in some cases, will define complex rules that determine whether or not a particular observation is made. Examples: "Blood pressure", "Full blood count", "Chemistry panel".
A group of entries within a composition, topic or category that have a logical association with one another. The representation of a single observation or action might itself be multi-part. The data might need to be represented as a nested set of values, as a table, list, or as a time series. The Cluster class permits such aggregation within an entry for such compound data. Examples include "Haematology investigations" which might include two or more distinct batteries. A cluster may contain batteries and/or individual entries
Description: An acquisition exposure act describes the proximity (location and time) through which the participating entity was potentially exposed to a physical (including energy), chemical or biological agent from another entity. The acquisition exposure act is used in conjunction with transmission exposure acts as part of an analysis technique for contact tracing. Although an exposure can be decomposed into transmission and acquisition exposures, there is no requirement that all exposures be treated in this fashion. Constraints: The Acquisition Exposure inherits the participation constraints that apply to Exposure with the following exception. The EXPSRC (exposure source) participation must never be associated with the Transmission Exposure either directly or via context conduction.
Description: A transmission exposure act describes the proximity (time and location) over which the participating source entity was capable of transmitting a physical (including energy), chemical or biological substance agent to another entity. The transmission exposure act is used in conjunction with acquisition exposure acts as part of an analysis technique for contact tracing. Although an exposure can be decomposed into transmission and acquisition exposures, there is no requirement that all exposures be treated in this fashion. Constraints: The Transmission Exposure inherits the participation constraints that apply to Exposure with the following exception. The EXPTRGT (exposure target) participation must never be associated with the Transmission Exposure either directly or via context conduction.
A context that comprises all compositions. The EHR is an extract that includes the entire chart. NOTE: In an exchange scenario, an EHR is a specialization of an extract.
When used in the EVN mood, this concept means with respect to a covered party: A health care insurance policy or plan that is contractually binding between two or more parties; or A health care program, usually administered by government entities, that provides coverage to persons determined eligible under the terms of the program. When used in the definition (DEF) mood, COV means potential coverage for a patient who may or may not be a covered party. The concept's meaning is fully specified by the choice of ActCoverageTypeCode (abstract) ActProgramCode or ActInsurancePolicyCode.
Description:A determinant peptide in a polypeptide as described by polypeptide.
Description:An expression level of genes/proteins or other expressed genomic entities.
Description:The position of a gene (or other significant sequence) on the genome.
Description:A genomic phenomenon that is expressed externally in the organism.
Description:A polypeptide resulting from the translation of a gene.
Description:A sequence of biomolecule like the DNA, RNA, protein and the like.
Description:A variation in a sequence as described by BioSequence.
Regions of Interest (ROI) within a subject Act. Primarily used for making secondary observations on a subset of a subject observation. The relationship between a ROI and its referenced Act is specified through an ActRelationship of type "subject" (SUBJ), which must always be present.
The spatial relationship of a subject whether human, other animal, or plant, to a frame of reference such as gravity or a collection device.
An observation identifying a potential adverse outcome as a result of an Act or combination of Acts. Examples: Detection of a drug-drug interaction; Identification of a late-submission for an invoice; Requesting discharge for a patient who does not meet hospital-defined discharge criteria. Discussion: This class is commonly used for identifying 'business rule' or 'process' problems that may result in a refusal to carry out a particular request. In some circumstances it may be possible to 'bypass' a problem by modifying the request to acknowledge the issue and/or by providing some form of mitigation. Constraints: the Act or Acts that may cause the the adverse outcome are the target of a subject ActRelationship. The subbtypes of this concept indicate the type of problem being detected (e.g. drug-drug interaction) while the Observation.value is used to repesent a specific problem code (e.g. specific drug-drug interaction id).
The set of actions that define an experiment to assess the effectiveness and/or safety of a biopharmaceutical product (food, drug, device, etc.). In definition mood, this set of actions is often embodied in a clinical trial protocol; in event mood, this designates the aggregate act of applying the actions to one or more subjects.
An instance of Observation of a Condition at a point in time that includes any Observations or Procedures associated with that Condition as well as links to previous instances of Condition Node for the same Condition
An observable finding or state that persists over time and tends to require intervention or management, and, therefore, distinguished from an Observation made at a point in time; may exist before an Observation of the Condition is made or after interventions to manage the Condition are undertaken. Examples: equipment repair status, device recall status, a health risk, a financial risk, public health risk, pregnancy, health maintenance, chronic illness
Class for holding attributes unique to diagnostic images.
Description:An observation of genomic phenomena.
An formalized inquiry into the circumstances surrounding a particular unplanned event or potential event for the purposes of identifying possible causes and contributing factors for the event. This investigation could be conducted at a local institutional level or at the level of a local or national government.
Container for Correlated Observation Sequences sharing a common frame of reference. All Observations of the same cd must be comparable and relative to the common frame of reference. For example, a 3-channel ECG device records a 12-lead ECG in 4 steps (3 leads at a time). Each of the separate 3-channel recordings would be in their own "OBSCOR". And, all 4 OBSCOR would be contained in one OBSSER because all the times are relative to the same origin (beginning of the recording) and all the ECG signals were from a fixed set of electrodes.
An observation denoting the physical location of a person or thing based on a reference coordinate system.
An observation on a specimen in a laboratory environment that may affect processing, analysis or result interpretation
An act which describes the process whereby a 'verifying party' validates either the existence of the Role attested to by some Credential or the actual Vetting act and its details.
Container for Observation Sequences (Observations whose values are contained in LIST<>'s) having values correlated with each other. Each contained Observation Sequence LIST<> must be the same length. Values in the LIST<>'s are correlated based on index. E.g. the values in position 2 in all the LIST<>'s are correlated. This is analogous to a table where each column is an Observation Sequence with a LIST<> of values, and each row in the table is a correlation between the columns. For example, a 12-lead ECG would contain 13 sequences: one sequence for time, and a sequence for each of the 12 leads.
A group of entries within a composition or topic that have a common characteristic - for example, Examination, Diagnosis, Management OR Subjective, Objective, Analysis, Plan. The distinction from Topic relates to value sets. For Category there is a bounded list of things like "Examination", "Diagnosis" or SOAP categories. For Topic the list is wide open to any clinical condition or reason for a part of an encounter. A CATEGORY MAY CONTAIN ENTRIES.
A context that distinguishes the body of a document from the document header. This is seen, for instance, in HTML documents, which have discrete and elements.
A context that subdivides the body of a document. Document sections are typically used for human navigation, to give a reader a clue as to the expected content. Document sections are used to organize and provide consistency to the contents of a document body. Document sections can contain document sections and can contain entries.
A group of entries within a composition that are related to a common clinical theme - such as a specific disorder or problem, prevention, screening and provision of contraceptive services. A topic may contain categories and entries.
An interaction between a patient and healthcare participant(s) for the purpose of providing patient service(s) or assessing the health status of a patient. For example, outpatient visit to multiple departments, home health support (including physical therapy), inpatient hospital stay, emergency room visit, field visit (e.g., traffic accident), office visit, occupational therapy, telephone call.
Description:A mandate, regulation, obligation, requirement, rule, or expectation unilaterally imposed by a jurisdiction on: The activity of another party The behavior of another party The manner in which an act is executed Examples:A jurisdictional mandate regarding the prescribing and dispensing of a particular medication. A jurisdictional privacy or security regulation dictating the manner in which personal health information is disclosed. A jurisdictional requirement that certain services or health conditions are reported to a monitoring program, e.g., immunizations, methadone treatment, or cancer registries.
Description:A mandate, obligation, requirement, rule, or expectation unilaterally imposed by an organization on: The activity of another party The behavior of another party The manner in which an act is executed Examples:A clinical or research protocols imposed by a payer, a malpractice insurer, or an institution to which a provider must adhere. A mandate imposed by a denominational institution for a provider to provide or withhold certain information from the patient about treatment options.
Description:An ethical or clinical obligation, requirement, rule, or expectation imposed or strongly encouraged by organizations that oversee particular clinical domains or provider certification which define the boundaries within which a provider may practice and which may have legal basis or ramifications on: The activity of another party The behavior of another party The manner in which an act is executed Examples:An ethical obligation for a provider to fully inform a patient about all treatment options. An ethical obligation for a provider not to disclose personal health information that meets certain criteria, e.g., where disclosure might result in harm to the patient or another person. The set of health care services which a provider is credentialed or privileged to provide.
Description:A requirement, rule, or expectation typically documented as guidelines, protocols, or formularies imposed or strongly encouraged by an organization that oversees or has authority over the practices within a domain, and which may have legal basis or ramifications on: The activity of another party The behavior of another party The manner in which an act is executed Examples:A payer may require a prescribing provider to adhere to formulary guidelines. An institution may adopt clinical guidelines and protocols and implement these within its electronic health record and decision support systems.
Description:An observation representing the degree to which the assignment of the spatial coordinates, based on a matching algorithm by a geocoding engine against a reference spatial database, matches true or accepted values.
Description:An observation representing one of a set of numerical values used to determine the position of a place. The name of the coordinate value is determined by the reference coordinate system.
A procedure for obtaining a specimen from a source entity.
Diet services are supply services, with some aspects resembling Medication services: the detail of the diet is given as a description of the Material associated via Participation.typeCode="product". Medically relevant diet types may be communicated in the Diet.code attribute using domain ActDietCode, however, the detail of the food supplied and the various combinations of dishes should be communicated as Material instances.
Lying on the back, on an inclined plane, typically about 30-45 degrees with head raised and feet lowered.
Lying on the back, on an inclined plane, typically about 30-45 degrees, with head lowered and feet raised.
A code specifying the particular kind of Act that the Act-instance represents within its class. Constraints: The kind of Act (e.g. physical examination, serum potassium, inpatient encounter, charge financial transaction, etc.) is specified with a code from one of several, typically external, coding systems. The coding system will depend on the class of Act, such as LOINC for observations, etc. Conceptually, the Act.code must be a specialization of the Act.classCode. This is why the structure of ActClass domain should be reflected in the superstructure of the ActCode domain and then individual codes or externally referenced vocabularies subordinated under these domains that reflect the ActClass structure. Act.classCode and Act.code are not modifiers of each other but the Act.code concept should really imply the Act.classCode concept. For a negative example, it is not appropriate to use an Act.code "potassium" together with and Act.classCode for "laboratory observation" to somehow mean "potassium laboratory observation" and then use the same Act.code for "potassium" together with Act.classCode for "medication" to mean "substitution of potassium". This mutually modifying use of Act.code and Act.classCode is not permitted.
Description:The type and scope of responsibility taken-on by the performer of the Act for a specific subject of care.
Denotes the specific service that has been performed. This is obtained from the professional service catalog pertaining to the discipline of the health service provider. Professional services are generally cognitive in nature and exclude surgical procedures. E.g. Provided training, Provided drug therapy review, Gave smoking-cessation counseling, etc.
Definition: The type of consent directive, e.g., to consent or dissent to collect, access, or use in specific ways within an EHRS or for health information exchange; or to disclose health information for purposes such as research.
Code identifying the type of identification document (e.g. passport, drivers license) Implementation Note:The proposal called for a domain, but a code was also provided. When codes are available for the value set the code IDENTDOC (identity document) will be used as the headcode for the specializable value set.
Definition: The type of personal health information to which the subject of the information or the subjectaTMs delegate consents or dissents to authorize access.
Definition:Indicates the set of information types which may be manipulated or referenced, such as for recommending access restrictions.
Description:Concepts representing indications (reasons for clinical action) other than diagnosis and symptoms.
Characterizes how a transportation act was or will be carried out. Examples: Via private transport, via public transit, via courier.
Description:Physicians Current Procedural Terminology (CPT) Manual is a listing of descriptive terms and identifying codes for reporting medical services and procedures performed by physicians. Available for the AMA at the address listed for CPT above. These codes are found in Appendix A of CPT 2000 Standard Edition. (CPT 2000 Standard Edition, American Medical Association, Chicago, IL).
Domain provides the root for HL7-defined detailed or rich codes for the Act classes.
Description: Includes those concepts that are provided to justify the fact that an adverse event or product problem is required to be reported in an expedited fashion.
Description: Includes relevant pieces of information about a product or its process of creation. The vocabulary domain is used to characterize products when they are cited in adverse event or product problem reports. Examples:Weight, color, dimensions.
Definition:The set of LOINC codes for the act of determining the period of time that has elapsed since an entity was born or created.
Description:To allow queries to specify useful information about the age of the patient without disclosing possible protected health information.
Identifies the kinds of observations that can be performed
Definition: A public or government health program that administers and funds coverage for prescription drugs to assist program eligible who meet financial and health status criteria.
The act of putting something away for safe keeping. The "something" may be physical object such as a specimen, or information, such as observations regarding a specimen.
Definition: A government health program that provides coverage on a fee for service basis for health services to persons meeting eligibility criteria such as income, location of residence, access to other coverages, health condition, and age, the cost of which is to some extent subsidized by public funds. Discussion: The structure and business processes for underwriting and administering a subsidized fee for service program is further specified by the Underwriter and Payer Role.class and Role.code.
A supply action that provides sufficient material for a single dose via multiple products. E.g. 2 50mg tablets for a 100mg unit dose.
Definition: Government mandated program providing coverage, disability income, and vocational rehabilitation for injuries sustained in the work place or in the course of employment. Employers may either self-fund the program, purchase commercial coverage, or pay a premium to a government entity that administers the program. Employees may be required to pay premiums toward the cost of coverage as well.
An account for collecting charges, reversals, adjustments and payments, including deductibles, copayments, coinsurance (financial transactions) credited or debited to the account receivable account for a patient's encounter.
An account representing charges and credits (financial transactions) for a patient's encounter.
The invoice element has been accepted for payment but one or more adjustment(s) have been made to one or more invoice element line items (component charges). Also includes the concept 'Adjudicate as zero' and items not covered under a particular Policy. Invoice element can be reversed (nullified). Recommend that the invoice element is saved for DUR (Drug Utilization Reporting).
The invoice element has passed through the adjudication process but payment is refused due to one or more reasons. Includes items such as patient not covered, or invoice element is not constructed according to payer rules (e.g. 'invoice submitted too late'). If one invoice element line item in the invoice element structure is rejected, the remaining line items may not be adjudicated and the complete group is treated as rejected. A refused invoice element can be forwarded to the next payer (for Coordination of Benefits) or modified and resubmitted to refusing payer. Invoice element cannot be reversed (nullified) as there is nothing to reverse. Recommend that the invoice element is not saved for DUR (Drug Utilization Reporting).
The invoice element was/will be paid exactly as submitted, without financial adjustment(s). If the dollar amount stays the same, but the billing codes have been amended or financial adjustments have been applied through the adjudication process, the invoice element is treated as "Adjudicated with Adjustment". If information items are included in the adjudication results that do not affect the monetary amounts paid, then this is still Adjudicated as Submitted (e.g. 'reached Plan Maximum on this Claim'). Invoice element can be reversed (nullified). Recommend that the invoice element is saved for DUR (Drug Utilization Reporting).
Transaction counts and value totals by Contract Identifier.
Transaction counts and value totals for each calendar day within the date range specified.
Transaction counts and value totals by service location (e.g clinic).
Transaction counts and value totals for each calendar month within the date range specified.
Transaction counts and value totals for the date range specified.
Transaction counts and value totals by Provider Identifier.
Transaction counts and value totals for each calendar week within the date range specified.
Transaction counts and value totals for each calendar year within the date range specified.
The adjudication result associated is to be displayed to the receiver of the adjudication result.
The adjudication result associated is to be printed on the specified form, which is then provided to the covered party.
The requesting party has insufficient authorization to invoke the interaction.
Description:The specified element did not pass business-rule validation.
The ID of the patient, order, etc., was not found. Used for transactions other than additions, e.g. transfer of a non-existent patient.
The ID of the patient, order, etc., already exists. Used in response to addition transactions (Admit, New Order, etc.).
Description:CPT modifier codes are found in Appendix A of CPT 2000 Standard Edition.
Description:HCPCS Level II (HCFA-assigned) and Carrier-assigned (Level III) modifiers are reported in Appendix A of CPT 2000 Standard Edition and in the Medicare Bulletin.
Definition: An identifying code for billable medical services, as opposed to codes for similar services to identify them for clinical purposes.
Definition: An identifying code for billable services that are not medical procedures, such as social services or governmental program services. Example: Building a wheelchair ramp, help with groceries, giving someone a ride, etc.
A billing arrangement where a Provider charges a lump sum to provide a prescribed group (volume) of services to a single patient which occur over a period of time. Services included in the block may vary. This billing arrangement is also known as Program of Care for some specific Payors and Program Fees for other Payors.
A billing arrangement where the payment made to a Provider is determined by analyzing one or more demographic attributes about the persons/patients who are enrolled with the Provider (in their practice).
A billing arrangement where a Provider charges a lump sum to provide a particular volume of one or more interventions/procedures or groups of interventions/procedures.
A billing arrangement where a Provider charges a separate fee for each intervention/procedure/event or product. Fee for Service is used when an individual intervention/procedure/event is used for billing purposes. In other words, fees are associated with the intervention/procedure/event. For example, a specific CCI (Canadian Classification of Interventions) code has an associated fee and is used for billing purposes.
A billing arrangement where a Provider charges for non-clinical items. This includes interest in arrears, mileage, etc. Clinical content is not included in Invoices submitted with this type of billing arrangement.
A billing arrangement where funding is based on a list of individuals registered as patients of the Provider.
A billing arrangement where a Provider charges a sum to provide a group (volume) of interventions/procedures to one or more patients within a defined period of time, typically on the same date. Interventions/procedures included in the session may vary.
A fully specified bounded Region of Interest (ROI) delineates a ROI in which only those dimensions participate that are specified by boundary criteria, whereas all other dimensions are excluded. For example a ROI to mark an episode of "ST elevation" in a subset of the EKG leads V2, V3, and V4 would include 4 boundaries, one each for time, V2, V3, and V4.
A partially specified bounded Region of Interest (ROI) specifies a ROI in which at least all values in the dimensions specified by the boundary criteria participate. For example, if an episode of ventricular fibrillations (VFib) is observed, it usually doesn't make sense to exclude any EKG leads from the observation and the partially specified ROI would contain only one boundary for time indicating the time interval where VFib was observed.
Description:The type and scope of legal and/or professional responsibility taken-on by the performer of the Act for a specific subject of care as described by a credentialing agency, i.e. government or non-government agency. Failure in executing this Act may result in loss of credential to the person or organization who participates as performer of the Act. Excludes employment agreements. Example:Hospital license; physician license; clinic accreditation.
Domain provides codes that qualify the ActEncounterClass (ENC)
Definition: Consent to have healthcare information collected in an electronic health record. This entails that the information may be used in analysis, modified, updated.
Definition: Consent to have collected healthcare information disclosed.
Definition: Consent to access healthcare information.
Definition: Information re-disclosed without the patient's consent.
Definition: Consent to have healthcare information in an electronic health record accessed for research purposes.
Used by one system to inform another that it has received a container.
Used by one system to inform another that the container is in position for specimen transfer (e.g., container removal from track, pipetting, etc.).
Used by one system to inform another that the container has been released from that system.
Used by one system to inform another that the container did not arrive at its next expected location.
Used by one system to inform another that the specific container is being processed by the equipment. It is useful as a response to a query about Container Status, when the specific step of the process is not relevant.
Status is used by one system to inform another that the processing has been completed, but the container has not been released from that system.
Used by one system to inform another that the container is no longer available within the scope of the system (e.g., tube broken or discarded).
Specifies whether or not automatic repeat testing is to be initiated on specimens.
A baseline value for the measured test that is inherently contained in the diluent. In the calculation of the actual result for the measured test, this baseline value is normally considered.
Specifies whether or not further testing may be automatically or manually initiated on specimens.
Authorization approved and funds have been set aside to pay for specified healthcare service(s) and/or product(s) within defined criteria for the authorization.
Authorization for specified healthcare service(s) and/or product(s) denied.
Indication of authorization for healthcare service(s) and/or product(s). If authorization is approved, funds are set aside.
Indication of eligibility coverage for healthcare service(s) and/or product(s).
Insurance coverage is in effect for healthcare service(s) and/or product(s).
Insurance coverage is not in effect for healthcare service(s) and/or product(s). May optionally include reasons for the ineligibility.
Maximum amount paid or maximum number of services/products covered; or maximum amount or number covered during a specified time period under the policy or program.
Codes representing the types of covered parties that may receive covered benefits under a policy or program.
Definition: Codes representing the maximum coverate or financial participation requirements.
Codes representing the time period during which coverage is available; or financial participation requirements are in effect.
Definition: Maximum amount paid by payer or covered party; or maximum number of services or products covered under the policy or program during a covered party's lifetime.
Maximum net amount that will be covered for the product or service specified.
Definition: Maximum amount paid by payer or covered party; or maximum number of services/products covered under the policy or program by time period specified by the effective time on the act.
Maximum unit price that will be covered for the authorized product or service.
Maximum number of items that will be covered of the product or service specified.
Set of codes indicating the type of insurance policy or other source of funds to cover healthcare costs.
Definition: Set of codes indicating the type of insurance policy. Insurance, in law and economics, is a form of risk management primarily used to hedge against the risk of potential financial loss. Insurance is defined as the equitable transfer of the risk of a potential loss, from one entity to another, in exchange for a premium and duty of care. A policy holder is an individual or an organization enters into a contract with an underwriter which stipulates that, in exchange for payment of a sum of money (a premium), one or more covered parties (insureds) is guaranteed compensation for losses resulting from certain perils under specified conditions. The underwriter analyzes the risk of loss, makes a decision as to whether the risk is insurable, and prices the premium accordingly. A policy provides benefits that indemnify or cover the cost of a loss incurred by a covered party, and may include coverage for services required to remediate a loss. An insurance policy contains pertinent facts about the policy holder, the insurance coverage, the covered parties, and the insurer. A policy may include exemptions and provisions specifying the extent to which the indemnification clause cannot be enforced for intentional tortious conduct of a covered party, e.g., whether the covered parties are jointly or severably insured. Discussion: In contrast to programs, an insurance policy has one or more policy holders, who own the policy. The policy holder may be the covered party, a relative of the covered party, a partnership, or a corporation, e.g., an employer. A subscriber of a self-insured health insurance policy is a policy holder. A subscriber of an employer sponsored health insurance policy is holds a certificate of coverage, but is not a policy holder; the policy holder is the employer. See CoveredRoleType.
Definition: A set of codes used to indicate coverage under a program. A program is an organized structure for administering and funding coverage of a benefit package for covered parties meeting eligibility criteria, typically related to employment, health, financial, and demographic status. Programs are typically established or permitted by legislation with provisions for ongoing government oversight. Regulations may mandate the structure of the program, the manner in which it is funded and administered, covered benefits, provider types, eligibility criteria and financial participation. A government agency may be charged with implementing the program in accordance to the regulation. Risk of loss under a program in most cases would not meet what an underwriter would consider an insurable risk, i.e., the risk is not random in nature, not financially measurable, and likely requires subsidization with government funds. Discussion: Programs do not have policy holders or subscribers. Program eligibles are enrolled based on health status, statutory eligibility, financial status, or age. Program eligibles who are covered parties under the program may be referred to as members, beneficiaries, eligibles, or recipients. Programs risk are underwritten by not for profit organizations such as governmental entities, and the beneficiaries typically do not pay for any or some portion of the cost of coverage. See CoveredPartyRoleType.
Codes representing the level of coverage provided under the policy or program in terms of the types of entities that may play covered parties based on their personal relationships or employment status.
Description:The type and scope of legal and/or professional responsibility taken-on by the performer of the Act for a specific subject of care as described by an agency for credentialing individuals.
Description:The type and scope of legal and/or professional responsibility taken-on by the performer of the Act for a specific subject of care as described by an agency for credentialing programs within organizations.
Description:Scope of responsibility taken on for specialty care as defined by the respective Specialty Board.
Description:Scope of responsibility taken-on for physician care of a patient as defined by a governmental licensing agency.
Description:Scope of responsibility taken on by an organization for care of a patient as defined by the respective accreditation agency.
Description:Scope of responsibility taken on by an organization for care of a patient as defined by the disease management certification agency.
Codes dealing with the management of Detected Issue observations for the administrative and patient administrative acts domains.
Codes dealing with the management of Detected Issue observations for the financial acts domain.
Order is performed as issued, but other action taken to mitigate potential adverse effects
Description:External value set for accommodation types used in the U.S. Health Care Financing Administration (HCFA) Common Procedure Coding System (HCPCS) including modifiers.
Description:Accommodation type. In Intent mood, represents the accommodation type requested. In Event mood, represents accommodation assigned/used. In Definition mood, represents the available accommodation type.
General category of medical service provided to the patient during their encounter.
A comprehensive term for health care provided in a healthcare facility (e.g. a practitioneraTMs office, clinic setting, or hospital) on a nonresident basis. The term ambulatory usually implies that the patient has come to the location and is not assigned to a bed. Sometimes referred to as an outpatient encounter.
A patient encounter that takes place at a dedicated healthcare service delivery location where the patient receives immediate evaluation and treatment, provided until the patient can be discharged or responsibility for the patient's care is transferred elsewhere (for example, the patient could be admitted as an inpatient or transferred to another facility.)
A patient encounter that takes place both outside a dedicated service delivery location and outside a patient's residence. Example locations might include an accident site and at a supermarket.
Healthcare encounter that takes place in the residence of the patient or a designee
A patient encounter where a patient is admitted by a hospital or equivalent facility, assigned to a location where patients generally stay at least overnight and provided with room, board, and continuous nursing service.
An encounter where the patient is admitted to a health care facility for a predetermined length of time, usually less than 24 hours.
A patient encounter where the patient and the practitioner(s) are not in the same physical location. Examples include telephone conference, email exchange, robotic surgery, and televideo conference.
Description: Exposure participants' interaction occurred in a child care setting
Description: An interaction where the exposure participants traveled in/on the same vehicle (not necessarily concurrently, e.g. both are passengers of the same plane, but on different flights of that plane).
Description: Exposure participants' interaction occurred during the course of health care delivery or in a health care delivery setting, but did not involve the direct provision of care (e.g. a janitor cleaning a patient's hospital room).
Description: Exposure interaction occurred in context of one providing care for the other, i.e. a babysitter providing care for a child, a home-care aide providing assistance to a paraplegic.
Description: Exposure participants' interaction occurred when both were patients being treated in the same (acute) health care delivery facility.
Description: Exposure participants' interaction occurred when one visited the other who was a patient being treated in a health care delivery facility.
Description: Exposure interaction occurred in context of domestic interaction, i.e. both participants reside in the same household.
Description: Exposure participants' interaction occurred in the course of one or both participants being incarcerated at a correctional facility
Description: Exposure interaction was intimate, i.e. participants are intimate companions (e.g. spouses, domestic partners).
Description: Exposure participants' interaction occurred in the course of one or both participants being resident at a long term care facility (second participant may be a visitor, worker, resident or a physical place or object within the facility).
Description: An interaction where the exposure participants were both present in the same location/place/space.
Description: Exposure participants' interaction occurred during the course of health care delivery by a provider (e.g. a physician treating a patient in her office).
Description: Exposure participants' interaction occurred in an academic setting (e.g., participants are fellow students, or student and teacher).
Description: An interaction where the exposure participants are social associates or members of the same extended family
Description: An interaction where the exposure participants shared or co-used a common substance (e.g. drugs, needles, or common food item).
Description: An interaction where the exposure participants traveled together in/on the same vehicle/trip (e.g. concurrent co-passengers).
Description: Exposure interaction occurred in a work setting, i.e. participants are co-workers.
A type of transaction that represents a charge for a service or product. Expressed in monetary terms.
A type of transaction that represents a reversal of a previous charge for a service or product. Expressed in monetary terms. It has the opposite effect of a standard charge.
Definition: A health insurance policy that that covers benefits for dental services.
Definition: A health insurance policy that covers benefits for healthcare services provided for named conditions under the policy, e.g., cancer, diabetes, or HIV-AIDS.
Definition: A health insurance policy that covers benefits for prescription drugs, pharmaceuticals, and supplies.
Private insurance policy that provides coverage in addition to other policies (e.g. in addition to a Public Healthcare insurance policy).
Definition: A health insurance policy that covers healthcare benefits by protecting covered parties from medical expenses arising from health conditions, sickness, or accidental injury as well as preventive care. Health insurance policies explicitly exclude coverage for losses insured under a disability policy, workers' compensation program, liability insurance (including automobile insurance); or for medical expenses, coverage for on-site medical clinics or for limited dental or vision benefits when these are provided under a separate policy. Discussion: Health insurance policies are offered by health insurance plans that typically reimburse providers for covered services on a fee-for-service basis, that is, a fee that is the allowable amount that a provider may charge. This is in contrast to managed care plans, which typically prepay providers a per-member/per-month amount or capitation as reimbursement for all covered services rendered. Health insurance plans include indemnity and healthcare services plans.
Insurance policy that provides for an allotment of funds replenished on a periodic (e.g. annual) basis. The use of the funds under this policy is at the discretion of the covered party.
Definition: An insurance policy that covers benefits for long-term care services people need when they no longer can care for themselves. This may be due to an accident, disability, prolonged illness or the simple process of aging. Long-term care services assist with activities of daily living including: Help at home with day-to-day activities, such as cooking, cleaning, bathing and dressing Care in the community, such as in an adult day care facility Supervised care provided in an assisted living facility Skilled care provided in a nursing home
Definition: Government mandated program providing coverage, disability income, and vocational rehabilitation for injuries sustained in the work place or in the course of employment. Employers may either self-fund the program, purchase commercial coverage, or pay a premium to a government entity that administers the program. Employees may be required to pay premiums toward the cost of coverage as well. Managed care policies specifically exclude coverage for losses insured under a disability policy, workers' compensation program, liability insurance (including automobile insurance); or for medical expenses, coverage for on-site medical clinics or for limited dental or vision benefits when these are provided under a separate policy. Discussion: Managed care policies are offered by managed care plans that contract with selected providers or health care organizations to provide comprehensive health care at a discount to covered parties and coordinate the financing and delivery of health care. Managed care uses medical protocols and procedures agreed on by the medical profession to be cost effective, also known as medical practice guidelines. Providers are typically reimbursed for covered services by a capitated amount on a per member per month basis that may reflect difference in the health status and level of services anticipated to be needed by the member.
Definition: A health insurance policy that covers benefits for mental health services and prescriptions.
Definition: A policy for a health plan that has features of both an HMO and a FFS plan. Like an HMO, a POS plan encourages the use its HMO network to maintain discounted fees with participating providers, but recognizes that sometimes covered parties want to choose their own provider. The POS plan allows a covered party to use providers who are not part of the HMO network (non-participating providers). However, there is a greater cost associated with choosing these non-network providers. A covered party will usually pay deductibles and coinsurances that are substantially higher than the payments when he or she uses a plan provider. Use of non-participating providers often requires the covered party to pay the provider directly and then to file a claim for reimbursement, like in an FFS plan.
Definition: A health insurance policy that covers benefits for substance use services.
Definition: Set of codes for a policy that provides coverage for health care expenses arising from vision services. A health insurance policy that covers benefits for vision care services, prescriptions, and products.
Definition: A code specifying the particular kind of Patient Safety Incident that the Incident class instance represents. Examples:"Medication incident", "slips, trips and falls incident".The actual value set for the domain will be determined by each (realm) implementation, whose Patient Safety terminology will be specific, although probably linked to the WHO Patient Safety Taxonomy that is currently under development
Incident or accident as the result of a motor vehicle accident
Incident or accident is the result of a school place accident.
Incident or accident is the result of a sporting accident.
Incident or accident is the result of a work place accident
Definition: Provide consent to view or access adverse drug reaction information for a patient.
Definition: Provide consent to view or access allergy information for a patient.
Definition: Provide consent to view or access demographics information for a patient.
Definition: Provide consent to view or access immunization information for a patient.
Definition: Provide consent to view or access lab test result information for a patient.
Definition: Provide consent to view or access medication information for a patient.
Definition: Provide consent to view or access medical condition information for a patient.
Definition: Provide consent to view or access common observation information for a patient.
Definition: Provide consent to view or access coverage policy or program information for a patient.
Definition: Provide consent to view or access provider information for a patient.
Definition: Provide consent to view or access professional service information for a patient.
Consent to collect, access, use, or disclose specified patient health information only after explicit consent.
Consent to collect, access, use, or disclose specified patient health information only in response to a court order.
Consent to collect, access, use, or disclose specified patient health information only if necessary to avert potential danger to other persons.
Consent to collect, access, use, or disclose specified patient health information only in an emergency.
Consent to collect, access, use, or disclose specified patient health information only if necessary to avert potential public welfare risk.
Definition:All information pertaining to a patient's allergy and intolerance records.
Definition:All information pertaining to a patient's common observation records (height, weight, blood pressure, temperature, etc.).
Definition:All information pertaining to a patient's demographics (such as name, date of birth, gender, address, etc).
Definition:All information pertaining to a patient's diagnostic image records (orders & results).
Definition:All information pertaining to a patient's vaccination records.
Definition:All information pertaining to a patient's medical condition records.
Definition:All information pertaining to a patient's professional service records (such as smoking cessation, counseling, medication review, mental health).
Definition:All information pertaining to a patient's medication records (orders, dispenses and other active medications).
Insurance policy for injuries sustained in an automobile accident. Will also typically covered non-named parties to the policy, such as pedestrians and passengers.
Insurance policy funded by a public health system such as a provincial or national health plan. Examples include BC MSP (British Columbia Medical Services Plan) OHIP (Ontario Health Insurance Plan), NHS (National Health Service).
Insurance policy for injuries sustained in the work place or in the course of employment.
Definition: Set of codes indicating the type of health insurance policy that covers health services provided to covered parties. A health insurance policy is a written contract for insurance between the insurance company and the policyholder, and contains pertinent facts about the policy owner (the policy holder), the health insurance coverage, the insured subscribers and dependents, and the insurer. Health insurance is typically administered in accordance with a plan, which specifies (1) the type of health services and health conditions that will be covered under what circumstances (e.g., exclusion of a pre-existing condition, service must be deemed medically necessary; service must not be experimental; service must provided in accordance with a protocol; drug must be on a formulary; service must be prior authorized; or be a referral from a primary care provider); (2) the type and affiliation of providers (e.g., only allopathic physicians, only in network, only providers employed by an HMO); (3) financial participations required of covered parties (e.g., co-pays, coinsurance, deductibles, out-of-pocket); and (4) the manner in which services will be paid (e.g., under indemnity or fee-for-service health plans, the covered party typically pays out-of-pocket and then file a claim for reimbursement, while health plans that have contractual relationships with providers, i.e., network providers, typically do not allow the providers to bill the covered party for the cost of the service until after filing a claim with the payer and receiving reimbursement).
Definition: An insurance policy that provides a regular payment to compensate for income lost due to the covered party's inability to work because of illness or injury.
Definition: An insurance policy under a benefit plan run by an employer or employee organization for the purpose of providing benefits other than pension-related to employees and their families. Typically provides health-related benefits, benefits for disability, disease or unemployment, or day care and scholarship benefits, among others. An employer sponsored health policy includes coverage of health care expenses arising from sickness or accidental injury, coverage for on-site medical clinics or for dental or vision benefits, which are typically provided under a separate policy. Coverage excludes health care expenses covered by accident or disability, workers' compensation, liability or automobile insurance.
Definition: An insurance policy that covers qualified benefits under a Flexible Benefit plan such as group medical insurance, long and short term disability income insurance, group term life insurance for employees only up to $50,000 face amount, specified disease coverage such as a cancer policy, dental and/or vision insurance, hospital indemnity insurance, accidental death and dismemberment insurance, a medical expense reimbursement plan and a dependent care reimbursement plan. Discussion: See UnderwriterRoleTypeCode flexible benefit plan which is defined as a benefit plan that allows employees to choose from several life, health, disability, dental, and other insurance plans according to their individual needs. Also known as cafeteria plans. Authorized under Section 125 of the Revenue Act of 1978.
Definition: A policy under which the insurer agrees to pay a sum of money upon the occurrence of the covered partys death. In return, the policyholder agrees to pay a stipulated amount called a premium at regular intervals. Life insurance indemnifies the beneficiary for the loss of the insurable interest that a beneficiary has in the life of a covered party. For persons related by blood, a substantial interest established through love and affection, and for all other persons, a lawful and substantial economic interest in having the life of the insured continue. An insurable interest is required when purchasing life insurance on another person. Specific exclusions are often written into the contract to limit the liability of the insurer; for example claims resulting from suicide or relating to war, riot and civil commotion. Discussion:A life insurance policy may be used by the covered party as a source of health care coverage in the case of a viatical settlement, which is the sale of a life insurance policy by the policy owner, before the policy matures. Such a sale, at a price discounted from the face amount of the policy but usually in excess of the premiums paid or current cash surrender value, provides the seller an immediate cash settlement. Generally, viatical settlements involve insured individuals with a life expectancy of less than two years. In countries without state-subsidized healthcare and high healthcare costs (e.g. United States), this is a practical way to pay extremely high health insurance premiums that severely ill people face. Some people are also familiar with life settlements, which are similar transactions but involve insureds with longer life expectancies (two to fifteen years).
Definition: A type of insurance that covers damage to or loss of the policyholderaTMs property by providing payments for damages to property damage or the injury or death of living subjects. The terms "casualty" and "liability" insurance are often used interchangeably. Both cover the policyholder's legal liability for damages caused to other persons and/or their property.
Definition: An agreement between two or more insurance companies by which the risk of loss is proportioned. Thus the risk of loss is spread and a disproportionately large loss under a single policy does not fall on one insurance company. Acceptance by an insurer, called a reinsurer, of all or part of the risk of loss of another insurance company. Discussion: Reinsurance is a means by which an insurance company can protect itself against the risk of losses with other insurance companies. Individuals and corporations obtain insurance policies to provide protection for various risks (hurricanes, earthquakes, lawsuits, collisions, sickness and death, etc.). Reinsurers, in turn, provide insurance to insurance companies. For example, an HMO may purchase a reinsurance policy to protect itself from losing too much money from one insured's particularly expensive health care costs. An insurance company issuing an automobile liability policy, with a limit of $100,000 per accident may reinsure its liability in excess of $10,000. A fire insurance company which issues a large policy generally reinsures a portion of the risk with one or several other companies. Also called risk control insurance or stop-loss insurance.
Definition: A risk or part of a risk for which there is no normal insurance market available. Insurance written by unauthorized insurance companies. Surplus lines insurance is insurance placed with unauthorized insurance companies through licensed surplus lines agents or brokers.
Definition: A form of insurance protection that provides additional liability coverage after the limits of your underlying policy are reached. An umbrella liability policy also protects you (the insured) in many situations not covered by the usual liability policies.
Codes representing adjustments to a Payment Advice such as retroactive, clawback, garnishee, etc.
Codes representing a grouping of invoice elements (totals, sub-totals), reported through a Payment Advice or a Statement of Financial Activity (SOFA). The code can represent summaries by day, location, payee, etc.
Bonus payments based on performance, volume, etc. as agreed to by the payor.
An amount still owing to the payor but the payment is 0$ and this cannot be settled until a future payment is made.
Fees deducted on behalf of a payee for tuition and continuing education.
Fees deducted on behalf of a payee for charges based on a shorter payment frequency (i.e. next day versus biweekly payments.
Fees deducted on behalf of a payee for charges based on a per-transaction or time-period (e.g. monthly) fee.
Payment is based on a payment intent for a previously submitted Invoice, based on formal adjudication results..
Payment initiated by the payor as the result of adjudicating a paper (original, may have been faxed) invoice.
An amount that was owed to the payor as indicated, by a carry forward adjusment, in a previous payment advice
Professional association fee that is collected by the payor from the practitioner/provider on behalf of the association
Retroactive adjustment such as fee rate adjustment due to contract negotiations.
Transaction counts and value totals by invoice type (e.g. RXDINV - Pharmacy Dispense)
Transaction counts and value totals by each instance of an invoice payee.
Transaction counts and value totals by each instance of an invoice payor.
Transaction counts and value totals by each instance of a messaging application on a single processor. It is a registered identifier known to the receivers.
Description:United Nations Standard Products and Services Classification, managed by Uniform Code Council (UCC): www.unspsc.org
Description:Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes are procedure identifying codes. HCPCS is Health Care Finance AdministrationaTMs (HFCA) coding scheme to group procedures performed for payment to providers. contains codes for medical equipment, injectable drugs, transportation services, and other services not found in CPT4.
Description:International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS) are procedure identifying codes. ICD-10-PCS describes the classification of inpatient procedures for statistical purposes.
Description:International Classification of Diseases, 9th Revision, Procedure Coding System (ICD-9-PCS) are procedure identifying codes. ICD-9-PCS describes the classification of inpatient procedures for statistical purposes.
An identifying data string for healthcare products.
An identifying data string for healthcare procedures.
An identifying data string for A substance used as a medication or in the preparation of medication.
The detail item codes to identify charges or changes to the total billing of a claim due to insurance rules and payments.
An identifying data string for oral health procedure codes, e.g. extract tooth.
An identifying data string for medical facility accommodations.
Description:Global Trade Item Number is an identifier for trade items developed by GS1 (comprising the former EAN International and Uniform Code Council).
Description:Universal Product Code is one of a wide variety of bar code languages widely used in the United States and Canada for items in stores.
That portion of the eligible charges which a covered party must pay for each service and/or product. It is a percentage of the eligible amount for the service/product that is typically charged after the covered party has met the policy deductible. This amount represents the covered party's coinsurance that is applied to a particular adjudication result. It is expressed as a negative dollar amount in adjudication results.
The covered party pays a percentage of the cost of covered services.
That portion of the eligible charges which a covered party must pay for each service and/or product. It is a defined amount per service/product of the eligible amount for the service/product. This amount represents the covered party's copayment that is applied to a particular adjudication result. It is expressed as a negative dollar amount in adjudication results.
That portion of the eligible charges which a covered party must pay in a particular period (e.g. annual) before the benefits are payable by the adjudicator. This amount represents the covered party's deductible that is applied to a particular adjudication result. It is expressed as a negative dollar amount in adjudication results.
The guarantor, who may be the patient, pays the entire charge for a service. Reasons for such action may include: there is no insurance coverage for the service (e.g. cosmetic surgery); the patient wishes to self-pay for the service; or the insurer denies payment for the service due to contractual provisions such as the need for prior authorization.
That total amount of the eligible charges which a covered party must periodically pay for services and/or products prior to the Medicaid program providing any coverage. This amount represents the covered party's spend down that is applied to a particular adjudication result. It is expressed as a negative dollar amount in adjudication results
The billable item codes to identify adjudicator specified components to the total billing of a claim.
The billable item codes to identify modifications to a billable item charge. As for example after hours increase in the office visit fee.
The billable item codes to identify provider supplied charges or changes to the total billing of a claim.
The billable item codes to identify modifications to a billable item charge by a tax factor applied to the amount. As for example 7% provincial sales tax.
Premium paid on service fees in compensation for practicing outside of normal working hours.
Premium paid on service fees in compensation for practicing in a remote location.
Premium paid on service fees in compensation for practicing at a location other than normal working location.
A charge to compensate the provider when a patient cancels an appointment with insufficient time for the provider to make another appointment with another patient.
A reduction in the amount charged as a percentage of the amount. For example a 5% discount for volume purchase.
A premium on a service fee is requested because, due to extenuating circumstances, the service took an extraordinary amount of time or supplies.
Under agreement between the parties (payor and provider), a guaranteed level of income is established for the provider over a specific, pre-determined period of time. The normal course of business for the provider is submission of fee-for-service claims. Should the fee-for-service income during the specified period of time be less than the agreed to amount, a top-up amount is paid to the provider equal to the difference between the fee-for-service total and the guaranteed income amount for that period of time. The details of the agreement may specify (or not) a requirement for repayment to the payor in the event that the fee-for-service income exceeds the guaranteed amount.
Anticipated or actual final fee associated with treating a patient.
Anticipated or actual initial fee associated with treating a patient.
An increase in the amount charged as a percentage of the amount. For example, 12% markup on product cost.
A charge to compensate the provider when a patient does not show for an appointment.
Anticipated or actual periodic fee associated with treating a patient. For example, expected billing cycle such as monthly, quarterly. The actual period (e.g. monthly, quarterly) is specified in the unit quantity of the Invoice Element.
The amount for a performance bonus that is being requested from a payor for the performance of certain services (childhood immunizations, influenza immunizations, mammograms, pap smears) on a sliding scale. That is, for 90% of childhood immunizations to a maximum of $2200/yr. An invoice is created at the end of the service period (one year) and a code is submitted indicating the percentage achieved and the dollar amount claimed.
A charge is requested because the patient failed to pick up the item and it took an amount of time to return it to stock for future use.
A charge to cover the cost of travel time and/or cost in conjuction with providing a service or product. It may be charged per kilometer or per hour based on the effective agreement.
Premium paid on service fees in compensation for providing an expedited response to an urgent situation.
Accommodation type. In Intent mood, represents the accommodation type requested. In Event mood, represents accommodation assigned/used. In Definition mood, represents the available accommodation type.
Federal tax on transactions such as the Goods and Services Tax (GST)
Tax levied by the provincial or state jurisdiction such as Provincial Sales Tax
Codes representing a grouping of invoice elements (totals, sub-totals), reported through a Payment Advice or a Statement of Financial Activity (SOFA). The code can represent summaries by day, location, payee and other cost elements such as bonus, retroactive adjustment and transaction fees.
Codes representing a service or product that is being invoiced (billed). The code can represent such concepts as "office visit", "drug X", "wheelchair" and other billable items such as taxes, service charges and discounts.
Type of invoice element that is used to assist in describing an Invoice that is either submitted for adjudication or for which is returned on adjudication results. Invoice elements of this type signify a grouping of one or more children (detail) invoice elements. They do not have intrinsic costing associated with them, but merely reflect the sum of all costing for it's immediate children invoice elements.
Total counts and total net amounts adjudicated for all Invoice Groupings that were adjudicated within a time period based on the adjudication date of the Invoice Grouping.
Total counts and total net amounts paid for all Invoice Groupings that were paid within a time period based on the payment date.
Total counts and total net amounts billed for all Invoice Groupings that were submitted within a time period. Adjudicated invoice elements are included.
Type of invoice element that is used to assist in describing an Invoice that is either submitted for adjudication or for which is returned on adjudication results. Invoice elements of this type signify a grouping of one or more children (detail) invoice elements. They do not have intrinsic costing associated with them, but merely reflect the sum of all costing for it's immediate children invoice elements. The domain is only specified for an intermediate invoice element group (non-root or non-top level) for an Invoice.
Type of invoice element that is used to assist in describing an Invoice that is either submitted for adjudication or for which is returned on adjudication results. Invoice elements of this type signify a grouping of one or more children (detail) invoice elements. They do not have intrinsic costing associated with them, but merely reflect the sum of all costing for it's immediate children invoice elements. Codes from this domain reflect the type of Invoice such as Pharmacy Dispense, Clinical Service and Clinical Product. The domain is only specified for the root (top level) invoice element group for an Invoice.
A grouping of invoice element groups and details including the ones specifying the compound ingredients being invoiced. It may also contain generic detail items such as markup.
A grouping of invoice element details including the one specifying an ingredient drug being invoiced. It may also contain generic detail items such as tax or markup.
A grouping of invoice element groups and details including the ones specifying the compound supplies being invoiced. It may also contain generic detail items such as markup.
A grouping of invoice element details including the one specifying the drug being invoiced. It may also contain generic detail items such as markup.
A grouping of invoice element details including the ones specifying the frame fee and the frame dispensing cost that are being invoiced.
A grouping of invoice element details including the ones specifying the lens fee and the lens dispensing cost that are being invoiced.
A grouping of invoice element details including the one specifying the product (good or supply) being invoiced. It may also contain generic detail items such as tax or discount.
Insurance coverage problems have been encountered. Additional explanation information to be supplied.
Electronic form with supporting or additional information to follow.
Fax with supporting or additional information to follow.
The medical service was provided to a patient in good faith that they had medical coverage, although no evidence of coverage was available before service was rendered.
Knowingly over the payor's published time limit for this invoice possibly due to a previous payor's delays in processing. Additional reason information will be supplied.
Manual review of the invoice is requested. Additional information to be supplied. This may be used in the case of an appeal.
The medical service and/or product was provided to a patient that has coverage in another jurisdiction.
The service provided is required for orthodontic purposes. If the covered party has orthodontic coverage, then the service may be paid.
Paper documentation (or other physical format) with supporting or additional information to follow.
Public Insurance has been exhausted. Invoice has not been sent to Public Insuror and therefore no Explanation Of Benefits (EOB) is provided with this Invoice submission.
Allows provider to explain lateness of invoice to a subsequent payor.
Rules of practice do not require a physician's referral for the provider to perform a billable service.
The same service was delivered within a time period that would usually indicate a duplicate billing. However, the repeated service is a medical necessity and therefore not a duplicate.
The service provided is not related to another billed service. For example, 2 unrelated services provided on the same day to the same patient which may normally result in a refused payment for one of the items.
The provider has received a verbal permission from an authoritative source to perform the service or supply the item being invoiced.
Clinical product invoice where the Invoice Grouping contains one or more billable item and is supported by clinical product(s). For example, a crutch or a wheelchair.
Clinical Services Invoice which can be used to describe a single service, multiple services or repeated services. [1] Single Clinical services invoice where the Invoice Grouping contains one billable item and is supported by one clinical service. For example, a single service for an office visit or simple clinical procedure (e.g. knee mobilization). [2] Multiple Clinical services invoice where the Invoice Grouping contains more than one billable item, supported by one or more clinical services. The services can be distinct and over multiple dates, but for the same patient. This type of invoice includes a series of treatments which must be adjudicated together. For example, an adjustment and ultrasound for a chiropractic session where fees are associated for each of the services and adjudicated (invoiced) together. [3] Repeated Clinical services invoice where the Invoice Grouping contains one or more billable item, supported by the same clinical service repeated over a period of time. For example, the same Chiropractic adjustment (service or treatment) delivered on 3 separate occasions over a period of time at the discretion of the provider (e.g. month).
A clinical Invoice Grouping consisting of one or more services and one or more product. Billing for these service(s) and product(s) are supported by multiple clinical billable events (acts). All items in the Invoice Grouping must be adjudicated together to be acceptable to the Adjudicator. For example , a brace (product) invoiced together with the fitting (service).
Invoice Grouping without clinical justification. These will not require identification of participants and associations from a clinical context such as patient and provider. Examples are interest charges and mileage.
A clinical Invoice Grouping consisting of one or more oral health services. Billing for these service(s) are supported by multiple clinical billable events (acts). All items in the Invoice Grouping must be adjudicated together to be acceptable to the Adjudicator.
HealthCare facility preferred accommodation invoice.
Pharmacy dispense invoice for a compound.
Pharmacy dispense invoice not involving a compound
Clinical services invoice where the Invoice Group contains one billable item for multiple clinical services in one or more sessions.
Vision dispense invoice for up to 2 lens (left and right), frame and optional discount. Eye exams are invoiced as a clinical service invoice.
Description:Describes the high level classification of professional services for grouping. Examples:Education, Counseling, Surgery, etc.
Codes used to identify different types of 'duration-based' working lists. Examples include "Continuous/Chronic", "Short-Term" and "As-Needed".
Provision of Alternate Level of Care to a patient in an acute bed. Patient is waiting for placement in a long-term care facility and is unable to return home.
Provision of diagnosis and treatment of diseases and disorders affecting the heart
Provision of recurring care for chronic illness.
Provision of treatment for oral health and/or dental surgery.
General care performed by a general practitioner or family doctor as a responsible provider for a patient.
Provision of diagnostic and/or therapeutic treatment.
Provision of care of women during pregnancy, childbirth and immediate postpartum period. Also known as Maternity.
Provision of treatment and/or diagnosis related to tumors and/or cancer.
Provision of care for patients who are living or dying from an advanced illness.
Provision of diagnosis and treatment of diseases and disorders affecting children.
Pharmaceutical care performed by a pharmacist.
Provision of treatment for physical injury.
Provision of treatment of psychiatric disorder relating to mental illness.
Definition:A list of medications which the patient is only expected to consume for the duration of the current order or limited set of orders and which is not expected to be renewed.
Definition:A list of medications which are expected to be continued beyond the present order and which the patient should be assumed to be taking unless explicitly stopped.
Definition:A list of medications which the patient is intended to be administered only once.
Definition:A list of medications which the patient will consume intermittently based on the behavior of the condition for which the medication is indicated.
A monitoring program that focuses on narcotics and/or commonly abused substances that are subject to legal restriction.
Description:A drug that can be prescribed (and reimbursed) only if it meets certain criteria.
Description:A drug that requires special access permission to be prescribed and dispensed.
Description:Contrast agent required for imaging study.
Description:Provision of prescription or direction to consume a product for purposes of bowel clearance in preparation for a colonoscopy.
Description:Provision of medication as a preventative measure during a treatment or other period of increased risk.
Description:Provision of medication during pre-operative phase; e.g., antibiotics before dental surgery or bowel prep before colon surgery.
Description:Provision of medication for pregnancy --e.g., vitamins, antibiotic treatments for vaginal tract colonization, etc.
List of acts representing a care plan. The acts can be in a varierty of moods including event (EVN) to record acts that have been carried out as part of the care plan.
A written order to a bank to pay the amount specified from funds on deposit.
Electronic Funds Transfer (EFT) deposit into the payee's bank account
A fill providing sufficient supply for one day
A supply action where there is no 'valid' order for the supplied medication. E.g. Emergency vacation supply, weekend supply (when prescriber is unavailable to provide a renewal prescription)
The initial fill against an order. (This includes initial fills against refill orders.)
A supply action to restock a smaller more local dispensary.
A fill against an order that has already been filled (or partially filled) at least once.
A supply action that provides sufficient material for a single dose.
Description:A mandate, obligation, requirement, rule, or expectation unilaterally imposed on benefit coverage under a policy or program by a sponsor, underwriter or payor on: The activity of another party The behavior of another party The manner in which an act is executed Examples:A clinical protocol imposed by a payer to which a provider must adhere in order to be paid for providing the service. A formulary from which a provider must select prescribed drugs in order for the patient to incur a lower copay.
Definition: An identifying code for billable services, as opposed to codes for similar services used to identify them for functional purposes.
Description:An identifying code for oral health interventions/procedures.
Temporary supply of a product without transfer of ownership for the product.
Definition: A program that covers the cost of services provided directly to a beneficiary who typically has no other source of coverage without charge.
Definition: A program that covers the cost of services provided to crime victims for injuries or losses related to the occurrence of a crime.
Definition: An employee assistance program is run by an employer or employee organization for the purpose of providing benefits and covering all or part of the cost for employees to receive counseling, referrals, and advice in dealing with stressful issues in their lives. These may include substance abuse, bereavement, marital problems, weight issues, or general wellness issues. The services are usually provided by a third-party, rather than the company itself, and the company receives only summary statistical data from the service provider. Employee's names and services received are kept confidential.
Definition: A set of codes used to indicate a government program that is an organized structure for administering and funding coverage of a benefit package for covered parties meeting eligibility criteria, typically related to employment, health and financial status. Government programs are established or permitted by legislation with provisions for ongoing government oversight. Regulation mandates the structure of the program, the manner in which it is funded and administered, covered benefits, provider types, eligibility criteria and financial participation. A government agency is charged with implementing the program in accordance to the regulation Example: Federal employee health benefit program in the U.S.
Definition: A government program that provides health coverage to individuals who are considered medically uninsurable or high risk, and who have been denied health insurance due to a serious health condition. In certain cases, it also applies to those who have been quoted very high premiums a" again, due to a serious health condition. The pool charges premiums for coverage. Because the pool covers high-risk people, it incurs a higher level of claims than premiums can cover. The insurance industry pays into the pool to make up the difference and help it remain viable.
Definition: Services provided directly and through contracted and operated indigenous peoples health programs. Example: Indian Health Service in the U.S.
Definition: A government program that provides coverage for health services to military personnel, retirees, and dependents. A covered party who is a subscriber can choose from among Fee-for-Service (FFS) plans, and their Preferred Provider Organizations (PPO), or Plans offering a Point of Service (POS) Product, or Health Maintenance Organizations. Example: In the U.S., TRICARE, CHAMPUS.
Definition: A government mandated program with specific eligibility requirements based on premium contributions made during employment, length of employment, age, and employment status, e.g., being retired, disabled, or a dependent of a covered party under this program. Benefits typically include ambulatory, inpatient, and long-term care, such as hospice care, home health care and respite care.
Definition: A social service program funded by a public or governmental entity. Example: Programs providing habilitation, food, lodging, medicine, transportation, equipment, devices, products, education, training, counseling, alteration of living or work space, and other resources to persons meeting eligibility criteria.
Definition: Services provided directly and through contracted and operated veteran health programs.
Description:Specimen has been received by the participating organization/department.
Description:Specimen has been placed into storage at a participating location.
Description:Specimen has been put in transit to a participating receiver.
The lowering of specimen pH through the addition of an acid
The act rendering alkaline by impregnating with an alkali; a conferring of alkaline qualities.
The removal of fibrin from whole blood or plasma through physical or chemical means
The passage of a liquid through a filter, accomplished by gravity, pressure or vacuum (suction).
The act or process by which an acid and a base are combined in such proportions that the resulting compound is neutral.
The addition of calcium back to a specimen after it was removed by chelating agents
The filtration of a colloidal substance through a semipermeable medium that allows only the passage of small molecules.
Describes the artificial blood identifier that is associated with the specimen.
An observation that reports the dilution of a sample.
Domain provides codes that qualify the ActLabObsEnvfctsCode domain. (Environmental Factors)
An observation that relates to factors that may potentially cause interference with the observation
An observation that reports the volume of a sample.
The introduction of a drug into a subject with the intention of altering its biologic state with the intent of improving its health status.
The introduction of an immunogen with the intent of stimulating an immune response, aimed at preventing subsequent infections by more viable agents.
Administration of the proposed therapy may be inappropriate or contraindicated as proposed
Supplying the product at this time may be inappropriate or indicate compliance issues with the associated therapy
A clinician creates a request for a service to be performed for a given patient.
A person enters documentation about a given patient.
A person (e.g., clinician, the patient herself) reviews patient information in the electronic medical record.
Definition:A collection of concepts that identifies different types of 'duration-based' mediation working lists. Examples:"Continuous/Chronic" "Short-Term" and "As Needed"
Definition: Characterizes how a patient was or will be transported to the site of a patient encounter. Examples: Via ambulance, via public transit, on foot.
Proposed therapy may be contraindicated or ineffective based on an existing or recent drug therapy
Proposed therapy may be inappropriate or ineffective based on the proposed start or end time.
There may be an issue with the patient complying with the intentions of the proposed therapy
Description:Proposed therapy may be contraindicated or ineffective based on an existing or recent drug therapy.
Proposed dosage instructions for therapy differ from standard practice.
The proposed therapy appears to duplicate an existing therapy
Description:Proposed therapy may be inappropriate or ineffective based on the proposed start or end time.
Proposed therapy may be inappropriate or contraindicated due to conditions or characteristics of the patient
Used to temporarily override normal authorization rules to gain access to data in a case of emergency. Use of this override code will typically be monitored, and a procedure to verify its proper use may be triggered when used.
Communication of an agent from a living subject or environmental source to a living subject through indirect contact via oral or nasal inhalation.
Communication of an agent from one animal to another proximate animal.
Communication of an agent from an animal to a proximate person.
Communication of an agent from one living subject to another living subject through direct contact with any body fluid.
Communication of an agent to a living subject through direct contact with blood or blood products whether the contact with blood is part of a therapeutic procedure or not.
Communication of an agent from a living subject or environmental source to a living subject via agent migration through intact skin.
Communication of an agent from an environmental surface or source to a living subject by direct contact.
Communication of an agent from a living subject or environmental source to a living subject through oral contact with material contaminated by person or animal fecal material.
Communication of an agent from an non-living material to a living subject through direct contact.
Communication of an agent from a food source to a living subject via oral consumption.
Communication of an agent from a person to a proximate person.
Communication of an agent to a living subject via an undetermined route.
Communication of an agent from one living subject to another living subject through direct contact with mammalian milk or colostrum.
Communication of an agent from any entity to a living subject while the living subject is in the patient role in a healthcare facility.
Communication of an agent from a living subject or environmental source to a living subject where the acquisition of the agent is not via the alimentary canal.
Communication of an agent from a living subject to the progeny of that living subject via agent migration across the maternal-fetal placental membranes while in utero.
Communication of an agent from one living subject to another living subject through direct contact with genital or oral tissues as part of a sexual act.
Communication of an agent from one living subject to another living subject through direct contact with blood or blood products where the contact with blood is part of a therapeutic procedure.
Communication of an agent from a living subject acting as a required intermediary in the agent transmission process to a recipient living subject via direct contact.
Communication of an agent from a contaminated water source to a living subject whether the water is ingested as a food or not. The route of entry of the water may be through any bodily orifice.
This Observation Series type contains waveforms of a "representative beat" (a.k.a. "median beat" or "average beat"). The waveform samples are measured in relative time, relative to the beginning of the beat as defined by the Observation Series effective time. The waveforms are not directly acquired from the subject, but rather algorithmically derived from the "rhythm" waveforms.
This Observation type contains ECG "rhythm" waveforms. The waveform samples are measured in absolute time (a.k.a. "subject time" or "effective time"). These waveforms are usually "raw" with some minimal amount of noise reduction and baseline filtering applied.
Accommodations used in the care of diseases that are transmitted through casual contact or respiratory transmission.
Accommodations in which there is only 1 bed.
Uniquely designed and elegantly decorated accommodations with many amenities available for an additional charge.
Accommodations in which there are 2 beds.
Accommodations in which there are 3 or more beds.
An account represents a grouping of financial transactions that are tracked and reported together with a single balance. Examples of account codes (types) are Patient billing accounts (collection of charges), Cost centers; Cash.
Includes coded responses that will occur as a result of the adjudication of an electronic invoice at a summary level and provides guidance on interpretation of the referenced adjudication results.
Catagorization of grouping criteria for the associated transactions and/or summary (totals, subtotals).
Explanatory codes that provide information derived by an Adjudicator during the course of adjudicating an invoice. Codes from this domain are purely informational and do not materially affect the adjudicated invoice. That is, these codes do not impact or explain financial adjustments to an invoice. A companion domain (ActAdjudicationReasonCode) includes reasons which have a financial impact on an Invoice (claim). Example adjudication information code is 54540 - Patient has reached Plan Maximum for current year.
Actions to be carried out by the recipient of the Adjudication Result information.
Definition:An identifying modifier code for healthcare interventions or procedures.
The type of provision(s) made for reimbursing for the deliver of healthcare services and/or goods provided by a Provider, over a specified period.
Identifies the type of attachment (document, XRAY, bit map image, etc.) included to support a healthcare claim. It will be a specification for the type of document (i.e. WCB First Report of Acccident - Form 8).
Constrains the ActCode to the domain of Container Registration
An observation form that determines parameters or attributes of an Act. Examples are the settings of a ventilator machine as parameters of a ventilator treatment act; the controls on dillution factors of a chemical analyzer as a parameter of a laboratory observation act; the settings of a physiologic measurement assembly (e.g., time skew) or the position of the body while measuring blood pressure. Control variables are forms of observations because just as with clinical observations, the Observation.code determines the parameter and the Observation.value assigns the value. While control variables sometimes can be observed (by noting the control settings or an actually measured feedback loop) they are not primary observations, in the sense that a control variable without a primary act is of no use (e.g., it makes no sense to record a blood pressure position without recording a blood pressure, whereas it does make sense to record a systolic blood pressure without a diastolic blood pressure).
Response to an insurance coverage eligibility query or authorization request.
Criteria that are applicable to the authorized coverage.
Definition: Set of codes indicating the type of insurance policy or program that pays for the cost of benefits provided to covered parties.
Identifies types of detected issues for Act class "ALRT"
Codes dealing with the management of Detected Issue observations
Concepts that identify the type or nature of exposure interaction. Examples include "household", "care giver", "intimate partner", "common space", "common substance", etc. to further describe the nature of interaction.
Set of codes indicating the type of incident or accident.
Concepts conveying the context in which consent to transfer specified patient health information for collection, access, use or disclosure applies.
Type of invoice element that is used to assist in describing an Invoice that is either submitted for adjudication or for which is returned on adjudication results.
Identifies the different types of summary information that can be reported by queries dealing with Statement of Financial Activity (SOFA). The summary information is generally used to help resolve balance discrepancies between providers and payors.
Provides codes associated with ActClass value of LIST (working list)
Identifies the type of verification investigation being undertaken with respect to the subject of the verification activity. Examples: Verification of eligibility for coverage under a policy or program - aka enrolled/covered by a policy or program Verification of record - e.g., person has record in an immunization registry Verification of enumeration - e.g. NPI Verification of Board Certification - provider specific Verification of Certification - e.g. JAHCO, NCQA, URAC Verification of Conformance - e.g. entity use with HIPAA, conformant to the CCHIT EHR system criteria Verification of Provider Credentials Verification of no adverse findings - e.g. on National Provider Data Bank, Health Integrity Protection Data Base (HIPDB)
The type of order that was fulfilled by the clinical service
Code identifying the method or the movement of payment instructions. Codes are drawn from X12 data element 591 (PaymentMethodCode)
Description:Types of policies that further specify the ActClassPolicy value set.
An Act which characterizes a Privilege can have additional observations to provide a finer definition of the requested or conferred privilege. This domain describes the categories under which this additional information is classified.
An identifying code for healthcare interventions/procedures.
The method that a product is obtained for use by the subject of the supply act (e.g. patient). Product examples are consumable or durable goods.
This is the domain of registry types. Examples include Master Patient Registry, Staff Registry, Employee Registry, Tumor Registry.
Set of codes related to specimen treatments
Identifies the type of observation that is made about a specimen that may affect its processing, analysis or further result interpretation
Describes the type of substance administration being performed.
Description: Represents types of consent that patient must sign prior to receipt of service, which is required for billing purposes. Examples: Advanced beneficiary medically necessity notice. Advanced beneficiary agreement to pay notice. Advanced beneficiary requests payer billed.
The trigger event referenced by the Control Act instance. Values are drawn from the available trigger events used in the release of HL7 identified by the versionCode.
Shape of the region on the object being referenced
The specific chemical or radiological substance administered or to be administered into the body for therapeutic effect.
Code set to define specialized/allowed diets
Description:There is a clinical issue for the therapy that makes continuation of the therapy inappropriate.
Proposed therapy may interact with certain foods
Proposed therapy may interact with an existing or recent therapeutic product
Identifies the total net amount of all Invoice Groupings that were adjudicated as payable prior to the specified time period (based on adjudication date), subsequently cancelled in the specified period and submitted electronically.
Identifies the total number of all Invoice Groupings that were adjudicated as payable prior to the specified time period (based on adjudication date), subsequently cancelled in the specified period and submitted electronically.
Identifies the total net amount of all Invoice Groupings that were adjudicated as payable prior to the specified time period (based on adjudication date), subsequently cancelled in the specified period and submitted manually.
Identifies the total number of all Invoice Groupings that were adjudicated as payable prior to the specified time period (based on adjudication date), subsequently cancelled in the specified period and submitted manually.
Identifies the total net amount of all Invoice Groupings that were adjudicated as payable during the specified time period (based on adjudication date), subsequently nullified in the specified period and submitted electronically.
Identifies the total number of all Invoice Groupings that were adjudicated as payable during the specified time period (based on adjudication date), subsequently nullified in the specified period and submitted electronically.
Identifies the total net amount of all Invoice Groupings that were adjudicated as payable during the specified time period (based on adjudication date), subsequently cancelled in the specified period and submitted manually.
Identifies the total number of all Invoice Groupings that were adjudicated as payable during the specified time period (based on adjudication date), subsequently cancelled in the specified period and submitted manually.
Identifies the total net amount of all Invoice Groupings that were adjudicated as payable prior to the specified time period (based on adjudication date) that do not match a specified payee (e.g. pay patient) and submitted electronically.
Identifies the total number of all Invoice Groupings that were adjudicated as payable prior to the specified time period (based on adjudication date) that do not match a specified payee (e.g. pay patient) and submitted electronically.
Identifies the total net amount of all Invoice Groupings that were adjudicated as payable prior to the specified time period (based on adjudication date) that do not match a specified payee (e.g. pay patient) and submitted manually.
Identifies the total number of all Invoice Groupings that were adjudicated as payable prior to the specified time period (based on adjudication date) that do not match a specified payee (e.g. pay patient) and submitted manually.
Identifies the total net amount of all Invoice Groupings that were adjudicated as payable during the specified time period (based on adjudication date) that do not match a specified payee (e.g. pay patient) and submitted electronically.
Identifies the total number of all Invoice Groupings that were adjudicated as payable during the specified time period (based on adjudication date) that do not match a specified payee (e.g. pay patient) and submitted electronically.
Identifies the total net amount of all Invoice Groupings that were adjudicated as payable during the specified time period (based on adjudication date) that do not match a specified payee (e.g. pay patient) and submitted manually.
Identifies the total number of all Invoice Groupings that were adjudicated as payable during the specified time period (based on adjudication date) that do not match a specified payee (e.g. pay patient) and submitted manually.
Identifies the total net amount of all Invoice Groupings that were adjudicated as payable prior to the specified time period (based on adjudication date) that match a specified payee (e.g. pay provider) and submitted electronically.
Identifies the total number of all Invoice Groupings that were adjudicated as payable prior to the specified time period (based on adjudication date) that match a specified payee (e.g. pay provider) and submitted electronically.
Identifies the total net amount of all Invoice Groupings that were adjudicated as payable prior to the specified time period (based on adjudication date) that match a specified payee (e.g. pay provider) and submitted manually.
Identifies the total number of all Invoice Groupings that were adjudicated as payable prior to the specified time period (based on adjudication date) that match a specified payee (e.g. pay provider) and submitted manually.
Identifies the total net amount of all Invoice Groupings that were adjudicated as payable during the specified time period (based on adjudication date) that match a specified payee (e.g. pay provider) and submitted electronically.
Identifies the total number of all Invoice Groupings that were adjudicated as payable during the specified time period (based on adjudication date) that match a specified payee (e.g. pay provider) and submitted electronically.
Identifies the total net amount of all Invoice Groupings that were adjudicated as payable during the specified time period (based on adjudication date) that match a specified payee (e.g. pay provider) and submitted manually.
Identifies the total number of all Invoice Groupings that were adjudicated as payable during the specified time period (based on adjudication date) that match a specified payee (e.g. pay provider) and submitted manually.
Identifies the total net amount of all Invoice Groupings that were adjudicated as refused prior to the specified time period (based on adjudication date) and submitted electronically.
Identifies the total number of all Invoice Groupings that were adjudicated as refused prior to the specified time period (based on adjudication date) and submitted electronically.
Identifies the total net amount of all Invoice Groupings that were adjudicated as refused prior to the specified time period (based on adjudication date) and submitted manually.
Identifies the total number of all Invoice Groupings that were adjudicated as refused prior to the specified time period (based on adjudication date) and submitted manually.
Identifies the total net amount of all Invoice Groupings that were adjudicated as refused during the specified time period (based on adjudication date) and submitted electronically.
Identifies the total number of all Invoice Groupings that were adjudicated as refused during the specified time period (based on adjudication date) and submitted electronically.
Identifies the total net amount of all Invoice Groupings that were adjudicated as refused during the specified time period (based on adjudication date) and submitted manually.
Identifies the total number of all Invoice Groupings that were adjudicated as refused during the specified time period (based on adjudication date) and submitted manually.
Identifies the total net amount of all Invoice Groupings that were paid prior to the specified time period (based on payment date), subsequently nullified in the specified period and submitted electronically.
Identifies the total number of all Invoice Groupings that were paid prior to the specified time period (based on payment date), subsequently nullified in the specified period and submitted electronically.
Identifies the total net amount of all Invoice Groupings that were paid prior to the specified time period (based on payment date), subsequently nullified in the specified period and submitted manually.
Identifies the total number of all Invoice Groupings that were paid prior to the specified time period (based on payment date), subsequently nullified in the specified period and submitted manually.
Identifies the total net amount of all Invoice Groupings that were paid during the specified time period (based on payment date), subsequently nullified in the specified period and submitted electronically.
Identifies the total number of all Invoice Groupings that were paid during the specified time period (based on payment date), subsequently cancelled in the specified period and submitted electronically.
Identifies the total net amount of all Invoice Groupings that were paid during the specified time period (based on payment date), subsequently nullified in the specified period and submitted manually.
Identifies the total number of all Invoice Groupings that were paid during the specified time period (based on payment date), subsequently nullified in the specified period and submitted manually.
Identifies the total net amount of all Invoice Groupings that were paid prior to the specified time period (based on payment date) that do not match a specified payee (e.g. pay patient) and submitted electronically.
Identifies the total number of all Invoice Groupings that were paid prior to the specified time period (based on payment date) that do not match a specified payee (e.g. pay patient) and submitted electronically.
Identifies the total net amount of all Invoice Groupings that were paid prior to the specified time period (based on payment date) that do not match a specified payee (e.g. pay patient) and submitted manually.
Identifies the total number of all Invoice Groupings that were paid prior to the specified time period (based on payment date) that do not match a specified payee (e.g. pay patient) and submitted manually.
Identifies the total net amount of all Invoice Groupings that were paid during the specified time period (based on payment date) that do not match a specified payee (e.g. pay patient) and submitted electronically.
Identifies the total number of all Invoice Groupings that were paid during the specified time period (based on payment date) that do not match a specified payee (e.g. pay patient) and submitted electronically.
Identifies the total net amount of all Invoice Groupings that were paid during the specified time period (based on payment date) that do not match a specified payee (e.g. pay patient) and submitted manually.
Identifies the total number of all Invoice Groupings that were paid during the specified time period (based on payment date) that do not match a specified payee (e.g. pay patient) and submitted manually.
Identifies the total net amount of all Invoice Groupings that were paid prior to the specified time period (based on payment date) that match a specified payee (e.g. pay provider) and submitted electronically.
Identifies the total number of all Invoice Groupings that were paid prior to the specified time period (based on payment date) that match a specified payee (e.g. pay provider) and submitted electronically.
Identifies the total net amount of all Invoice Groupings that were paid prior to the specified time period (based on payment date) that match a specified payee (e.g. pay provider) and submitted manually.
Identifies the total number of all Invoice Groupings that were paid prior to the specified time period (based on payment date) that match a specified payee (e.g. pay provider) and submitted manually.
Identifies the total net amount of all Invoice Groupings that were paid during the specified time period (based on payment date) that match a specified payee (e.g. pay provider) and submitted electronically.
Identifies the total number of all Invoice Groupings that were paid during the specified time period (based on payment date) that match a specified payee (e.g. pay provider) and submitted electronically.
Identifies the total net amount of all Invoice Groupings that were paid during the specified time period (based on payment date) that match a specified payee (e.g. pay provider) and submitted manually.
Identifies the total number of all Invoice Groupings that were paid during the specified time period (based on payment date) that match a specified payee (e.g. pay provider) and submitted manually.
Identifies the total net amount billed for all submitted Invoice Groupings within a time period and submitted electronically. Adjudicated invoice elements are included.
Identifies the total number of submitted Invoice Groupings within a time period and submitted electronically. Adjudicated invoice elements are included.
Identifies the total net amount billed for all submitted Invoice Groupings that were nullified within a time period and submitted electronically. Adjudicated invoice elements are included.
Identifies the total number of submitted Invoice Groupings that were nullified within a time period and submitted electronically. Adjudicated invoice elements are included.
Identifies the total net amount billed for all submitted Invoice Groupings that are pended or held by the payor, within a time period and submitted electronically. Adjudicated invoice elements are not included.
Identifies the total number of submitted Invoice Groupings that are pended or held by the payor, within a time period and submitted electronically. Adjudicated invoice elements are not included.
Definition:General specification of age with no implied method of determination.
Definition:Age at onset of associated adverse event; no implied method of determination.
Description:This observation represents an 'average' or 'expected' half-life typical of the product.
Definition: A characteristic of an oral solid dosage form of a medicinal product, indicating whether it has one or more coatings such as sugar coating, film coating, or enteric coating. Only coatings to the external surface or the dosage form should be considered (for example, coatings to individual pellets or granules inside a capsule or tablet are excluded from consideration). Constraints: The Observation.value must be a Boolean (BL) with true for the presence or false for the absence of one or more coatings on a solid dosage form.
Definition: A characteristic of an oral solid dosage form of a medicinal product, specifying the color or colors that most predominantly define the appearance of the dose form. SPLCOLOR is not an FDA specification for the actual color of solid dosage forms or the names of colors that can appear in labeling. Constraints: The Observation.value must be a single coded value or a list of multiple coded values, specifying one or more distinct colors that approximate of the color(s) of distinct areas of the solid dosage form, such as the different sides of a tablet or one-part capsule, or the different halves of a two-part capsule. Bands on banded capsules, regardless of the color, are not considered when assigning an SPLCOLOR. Imprints on the dosage form, regardless of their color are not considered when assigning an SPLCOLOR. If more than one color exists on a particular side or half, then the most predominant color on that side or half is recorded. If the gelatin capsule shell is colorless and transparent, use the predominant color of the contents that appears through the colorless and transparent capsule shell. Colors can include: Black;Gray;White;Red;Pink;Purple;Green;Yellow;Orange;Brown;Blue;Turquoise.
Description: A characteristic representing a single file reference that contains two or more views of the same dosage form of the product; in most cases this should represent front and back views of the dosage form, but occasionally additional views might be needed in order to capture all of the important physical characteristics of the dosage form. Any imprint and/or symbol should be clearly identifiable, and the viewer should not normally need to rotate the image in order to read it. Images that are submitted with SPL should be included in the same directory as the SPL file.
Definition: A characteristic of an oral solid dosage form of a medicinal product, specifying the alphanumeric text that appears on the solid dosage form, including text that is embossed, debossed, engraved or printed with ink. The presence of other non-textual distinguishing marks or symbols is recorded by SPLSYMBOL. Examples: Included in SPLIMPRINT are alphanumeric text that appears on the bands of banded capsules and logos and other symbols that can be interpreted as letters or numbers. Constraints: The Observation.value must be of type Character String (ST). Excluded from SPLIMPRINT are internal and external cut-outs in the form of alphanumeric text and the letter 'R' with a circle around it (when referring to a registered trademark) and the letters 'TM' (when referring to a 'trade mark'). To record text, begin on either side or part of the dosage form. Start at the top left and progress as one would normally read a book. Enter a semicolon to show separation between words or line divisions.
Definition: A characteristic of an oral solid dosage form of a medicinal product, specifying the number of equal pieces that the solid dosage form can be divided into using score line(s). Example: One score line creating two equal pieces is given a value of 2, two parallel score lines creating three equal pieces is given a value of 3. Constraints: Whether three parallel score lines create four equal pieces or two intersecting score lines create two equal pieces using one score line and four equal pieces using both score lines, both have the scoring value of 4. Solid dosage forms that are not scored are given a value of 1. Solid dosage forms that can only be divided into unequal pieces are given a null-value with nullFlavor other (OTH).
Description: A characteristic of an oral solid dosage form of a medicinal product, specifying the two dimensional representation of the solid dose form, in terms of the outside perimeter of a solid dosage form when the dosage form, resting on a flat surface, is viewed from directly above, including slight rounding of corners. SPLSHAPE does not include embossing, scoring, debossing, or internal cut-outs. SPLSHAPE is independent of the orientation of the imprint and logo. Shapes can include: Triangle (3 sided); Square; Round; Semicircle; Pentagon (5 sided); Diamond; Double circle; Bullet; Hexagon (6 sided); Rectangle; Gear; Capsule; Heptagon (7 sided); Trapezoid; Oval; Clover; Octagon (8 sided); Tear; Freeform.
Definition: A characteristic of an oral solid dosage form of a medicinal product, specifying the longest single dimension of the solid dosage form as a physical quantity in the dimension of length (e.g., 3 mm). The length is should be specified in millimeters and should be rounded to the nearest whole millimeter. Example: SPLSIZE for a rectangular shaped tablet is the length and SPLSIZE for a round shaped tablet is the diameter.
Definition: A characteristic of an oral solid dosage form of a medicinal product, to describe whether or not the medicinal product has a mark or symbol appearing on it for easy and definite recognition. Score lines, letters, numbers, and internal and external cut-outs are not considered marks or symbols. See SPLSCORING and SPLIMPRINT for these characteristics. Constraints: The Observation.value must be a Boolean (BL) with true indicating the presence and false for the absence of marks or symbols. Example:
Admitting diagnosis are the diagnoses documented for administrative purposes as the basis for a hospital admission.
Discharge diagnosis are the diagnoses documented for administrative purposes as the time of hospital discharge.
Intermediate diagnoses are those diagnoses documented for administrative purposes during the course of a hospital stay.
The type of injury that the injury coding specifies.
Code for the mechanism by which disease was acquired by the living subject involved in the public health case. Includes sexually transmitted, airborne, bloodborne, vectorborne, foodborne, zoonotic, nosocomial, mechanical, dermal, congenital, environmental exposure, indeterminate.
A sequence of values in the "absolute" time domain. This is the same time domain that all HL7 timestamps use. It is time as measured by the Gregorian calendar
A sequence of values in a "relative" time domain. The time is measured relative to the earliest effective time in the Observation Series containing this sequence.
This domain includes observations used to characterize a privilege, under which this additional information is classified. Examples:A privilege to prescribe drugs has a RESTRICTION that excludes prescribing narcotics; a surgical procedure privilege has a PRE-CONDITION that it requires prior Board approval.
Definition: Indicates the class of actions taken with regard to a substance administration related adverse event. This characterization offers a judgment of the practitioner's response to the patient's problem. Examples: Example values include dose withdrawn, dose reduced, dose not changed. NOTE: The concept domain is currently supported by a value set created by the International Conference on Harmonization
Used in a patient care message to report and query simple clinical (non-lab) observations.
A code that is used to indicate the type of case safety report received from sender. The current code example reference is from the International Conference on Harmonisation (ICH) Expert Workgroup guideline on Clinical Safety Data Management: Data Elements for Transmission of Individual Case Safety Reports. The unknown/unavailable option allows the transmission of information from a secondary sender where the initial sender did not specify the type of report. Example concepts include: Spontaneous, Report from study, Other.
Description:Dianostic procedures ordered or performed to evaluate whether a sensitivity to a substance is present. This test may be associated with specimen collection and/or substance administration challenge actiivities. Example:Skin tests and eosinophilia evaluations.
Indicates the type of allergy test performed or to be performed. E.g. the specific antibody or skin test performed
Description:A kind of observation that allows a Secondary Observation (source act) to assert (at various levels of probability) that the target act of the association (which may be of any type of act) is implicated in the etiology of another observation that is named as the subject of the Secondary Observation Example:Causality assertions where an accident is the cause of a symptom; predisposition assertions where the genetic state plus environmental factors are implicated in the development of a disease; reaction assertions where a substance exposure is associated with a finding of wheezing.
Includes all codes defining types of indications such as diagnosis, symptom and other indications such as contrast agents for lab tests.
Definition: The set of observation type concepts that can be used to express pre-conditions to a particular dosage definition. Rationale: Used to constrain the set of observations to those related to the applicability of a dosage, such as height, weight, age, pregnancy, liver function, kidney function, etc. For example, in drug master-file type records indicating when a specified dose is applicable.
Distinguishes the kinds of coded observations that could be the trigger for clinical issue detection. These are observations that are not measurable, but instead can be defined with codes. Coded observation types include: Allergy, Intolerance, Medical Condition, Pregnancy status, etc.
Distinguishes between the kinds of measurable observations that could be the trigger for clinical issue detection. Measurable observation types include: Lab Results, Height, Weight.
Definition: An observation related to a query response. Example:The degree of match or match weight returned by a matching algorithm in a response to a query.
Definition: Identifies the type of Vision Prescription Observation that is being described.
Indicates the type of characteristics a patient should have for a given therapy to be appropriate. E.g. Weight, Age, certain lab values, etc.
Types of measurement observations typically performed in a clinical (non-lab) setting. E.g. Height, Weight, Blood-pressure
Indicates that the observation is of an unexpected negative occurrence in the subject suspected to result from the subject's exposure to one or more agents. Observation values would be the symptom resulting from the reaction.
Description:Refines classCode OBS to indicate an observation in which observation.value contains a finding or other nominalized statement, where the encoded information in Observation.value is not altered by Observation.code. For instance, observation.code="ASSERTION" and observation.value="fracture of femur present" is an assertion of a clinical finding of femur fracture.
Hypersensitivity resulting in an adverse reaction upon exposure to an agent.
Indicates a subjective evaluation of the criticality associated with another observation.
A circle defined by two (column,row) pairs. The first point is the center of the circle and the second point is a point on the perimeter of the circle.
An ellipse defined by four (column,row) pairs, the first two points specifying the endpoints of the major axis and the second two points specifying the endpoints of the minor axis.
A single point denoted by a single (column,row) pair, or multiple points each denoted by a (column,row) pair.
A series of connected line segments with ordered vertices denoted by (column,row) pairs; if the first and last vertices are the same, it is a closed polygon.
The patient is receiving a subsequent fill significantly later than would be expected based on the amount previously supplied and the therapy dosage instructions
The patient is receiving a subsequent fill significantly earlier than would be expected based on the amount previously supplied and the therapy dosage instructions
Proposed therapy may be inappropriate or ineffective because the end of administration is too close to another planned therapy
Proposed therapy may be inappropriate or ineffective because the start of administration is too late after the onset of the condition
Consulted other supplier/pharmacy, therapy confirmed
Assessed patient, therapy is appropriate
Consulted other supply source, therapy still appropriate
Concurrent therapy triggering alert is no longer on-going or planned
Patient's existing supply was lost/wasted
Supply date is intended to carry patient over weekend
Supply is intended for use during a leave of absence from an institution.
Consulted prescriber and recommended change, prescriber declined
Provided education or training to the patient on appropriate therapy use
Instituted an additional therapy to mitigate potential negative effects
Suspended existing therapy that triggered interaction for the duration of this therapy
Aborted existing therapy that triggered interaction.
Arranged to monitor patient for adverse effects
The invoice element has been accepted for payment but one or more adjustment(s) have been made to one or more invoice element line items (component charges) without changing the amount. Invoice element can be reversed (nullified). Recommend that the invoice element is saved for DUR (Drug Utilization Reporting).
Proposed dosage exceeds standard practice for the patient's age
Proposed dosage is below suggested therapeutic levels for the patient's age
An allergy to a substance other than a drug or a food. E.g. Latex, pollen, etc.
An allergy to a substance generally consumed for nutritional purposes.
Definition: An automobile insurance policy under which the insurance company will cover the cost of damages to an automobile owned by the named insured that are caused by accident or intentionally by another party.
Definition: An automobile insurance policy under which the insurance company will indemnify a loss for which another motorist is liable if that motorist is unable to pay because he or she is uninsured. Coverage under the policy applies to bodily injury damages only. Injuries to the covered party caused by a hit-and-run driver are also covered.
A clinician enters a diagnosis for a given patient.
A clinician enters a discharge summary for a given patient.
A pathologist enters a report for a given patient.
A clinician enters a problem for a given patient.
A radiologist enters a report for a given patient.
A person reviews a discharge summary of a given patient.
Description:The specified code has been deprecated and should no longer be used. Select another code from the code system.
Description:The proposed therapy is frequently misused or abused and therefore should be used with caution and/or monitoring.
Description:The request is suspected to have a fraudulent basis.
A similar or identical therapy was recently ordered by a different practitioner.
This patient was recently supplied a similar or identical therapy from a different pharmacy or supplier.
Proposed therapy may be inappropriate or contraindicated when breast-feeding
Proposed therapy may be inappropriate or contraindicated during pregnancy
A diet exclusively composed of oatmeal, semolina, or rice, to be extremely easy to eat and digest.
A diet that uses carbohydrates sparingly. Typically with a restriction in daily energy content (e.g. 1600-2000 kcal).
No enteral intake of foot or liquids whatsoever, no smoking. Typically 6 to 8 hours before anesthesia.
A diet low in fat, particularly to patients with hepatic diseases.
A low protein diet for patients with renal failure.
A strictly liquid diet, that can be fully absorbed in the intestine, and therefore may not contain fiber. Used before enteral surgeries.
A diet low in sodium for patients with congestive heart failure and/or renal failure.
A normal diet, i.e. no special preparations or restrictions for medical reasons. This is notwithstanding any preferences the patient might have regarding special foods, such as vegetarian, kosher, etc.
A no fat diet for acute hepatic diseases.
Patient is supplied with parenteral nutrition, typically described in terms of i.v. medications.
A diet that seeks to reduce body fat, typically low energy content (800-1600 kcal).
A diet that avoids ingredients that might cause digestion problems, e.g., avoid excessive fat, avoid too much fiber (cabbage, peas, beans).
This is not really a diet, since it contains little nutritional value, but is essentially just water. Used before coloscopy examinations.
Diet with low content of the amino-acids valin, leucin, and isoleucin, for "maple syrup disease."
The dilution of a sample performed by automated equipment. The value is specified by the equipment
The dilution of the specimen made prior to being loaded onto analytical equipment
The value of the dilution of a sample after it had been analyzed at a prior dilution value
Hypersensitivity to an agent caused by a mechanism other than an immunologic response to an initial exposure
Definition: A program that provides low-income, uninsured, and underserved women access to timely, high-quality screening and diagnostic services, to detect breast and cervical cancer at the earliest stages. Example: To improve women's access to screening for breast and cervical cancers, Congress passed the Breast and Cervical Cancer Mortality Prevention Act of 1990, which guided CDC in creating the National Breast and Cervical Cancer Early Detection Program (NBCCEDP), which provides access to critical breast and cervical cancer screening services for underserved women in the United States. An estimated 7 to 10% of U.S. women of screening age are eligible to receive NBCCEDP services. Federal guidelines establish an eligibility baseline to direct services to uninsured and underinsured women at or below 250% of federal poverty level; ages 18 to 64 for cervical screening; ages 40 to 64 for breast screening.
Definition: A public or government program that administers publicly funded coverage of kidney dialysis and kidney transplant services. Example: In the U.S., the Medicare End-stage Renal Disease program (ESRD), the National Kidney Foundation (NKF) American Kidney Fund (AKF) The Organ Transplant Fund.
Definition: Government administered and funded HIV-AIDS program for beneficiaries meeting financial and health status criteria. Administration, funding levels, eligibility criteria, covered benefits, provider types, and financial participation are typically set by a regulatory process. Payer responsibilities for administering the program may be delegated to contractors. Example: In the U.S., the Ryan White program, which is administered by the Health Resources and Services Administration.
Description:Proposed dosage is inappropriate due to patient's medical condition.
Proposed length of therapy differs from standard practice.
Proposed dosage exceeds standard practice
Proposed dosage interval/timing differs from standard practice
Proposed dosage is below suggested therapeutic levels
Description:The maximum quantity of this drug allowed to be administered within a particular time-range (month, year, lifetime) has been reached or exceeded.
Proposed length of therapy is longer than standard practice
Proposed length of therapy is shorter than that necessary for therapeutic effect
Proposed length of therapy is longer than standard practice for the identified indication or diagnosis
Proposed length of therapy is shorter than standard practice for the identified indication or diagnosis
Proposed dosage exceeds standard practice for the patient's height or body surface area
Proposed dosage exceeds standard practice for the patient's weight
Proposed dosage interval/timing differs from standard practice for the identified indication or diagnosis
Proposed dosage is below suggested therapeutic levels for the patient's height or body surface area
Proposed dosage is below suggested therapeutic levels for the patient's weight
Description:The proposed therapy appears to have the same intended therapeutic benefit as an existing therapy, though the specific mechanisms of action vary.
Description:The proposed therapy appears to have the same intended therapeutic benefit as an existing therapy and uses the same mechanisms of action as the existing therapy.
An emergency supply where the expectation is that a formal order authorizing the supply will be provided at a later date.
A first fill where the quantity supplied is equal to one full repetition of the ordered amount. (e.g. If the order was 90 tablets, 3 refills, a complete fill would be for the full 90 tablets).
A first fill where the quantity supplied is less than one full repetition of the ordered amount. (e.g. If the order was 90 tablets, 3 refills, a partial fill might be for only 30 tablets.)
A first fill where the quantity supplied is less than one full repetition of the ordered amount. (e.g. If the order was 90 tablets, 3 refills, a partial fill might be for only 30 tablets.) and also where the strength supplied is less than the ordered strength (e.g. 10mg for an order of 50mg where a subsequent fill will dispense 40mg tablets)
A fill where a small portion is provided to allow for determination of the therapy effectiveness and patient tolerance.
A fill where a small portion is provided to allow for determination of the therapy effectiveness and patient tolerance and also where the strength supplied is less than the ordered strength (e.g. 10mg for an order of 50mg where a subsequent fill will dispense 40mg tablets).
A first fill where the quantity supplied is equal to one full repetition of the ordered amount. (e.g. If the order was 90 tablets, 3 refills, a complete fill would be for the full 90 tablets) and also where the strength supplied is less than the ordered strength (e.g. 10mg for an order of 50mg where a subsequent fill will dispense 40mg tablets).
An additional immunization administration within a series intended to bolster or enhance immunity.
The first immunization administration in a series intended to produce immunity
Any category of inpatient encounter except 'acute'
Definition: Consent to access or "read" only, which entails that the information is not to be copied, screen printed, saved, emailed, stored, re-disclosed or altered in any way. This level ensures that data which is masked or to which access is restricted will not be. Example: Opened and then emailed or screen printed for use outside of the consent directive purpose.
Definition: Consent to access and save only, which entails that access to the saved copy will remain locked.
The Fibrin Index of the specimen. In the case of only differentiating between Absent and Present, recommend using 0 and 1
An observation of the hemolysis index of the specimen in g/L
An observation that describes the icterus index of the specimen. It is recommended to use mMol/L of bilirubin
An observation used to describe the Lipemia Index of the specimen. It is recommended to use the optical turbidity at 600 nm (in absorbance units).
Identifies types of detectyed issues for Act class "ALRT" for the administrative and patient administrative acts domains.
Identifies types of detected issues for Act class "ALRT" for the financial acts domain.
Identifies types of detected issues regarding the administration or supply of an item to a patient.
Identifies types of issues detected regarding the performance of a clinical action on a patient.
Description:The length of the data specified is greater than the maximum length defined for the element.
Description:The length of the data specified is less than the minimum length defined for the element.
Definition: A policy that, after an initial premium or premiums, pays out a sum at pre-determined intervals. For example, a policy holder may pay $10,000, and in return receive $150 each month until he dies; or $1,000 for each of 14 years or death benefits if he dies before the full term of the annuity has elapsed.
Definition: Life insurance under which the benefit is payable only if the insured dies during a specified period. If an insured dies during that period, the beneficiary receives the death payments. If the insured survives, the policy ends and the beneficiary receives nothing.
Definition: Life insurance under which the benefit is payable upon the insuredaTMs death or diagnosis of a terminal illness. If an insured dies during that period, the beneficiary receives the death payments. If the insured survives, the policy ends and the beneficiary receives nothing
Temporary supply of a product with financial compensation, without transfer of ownership for the product.
Definition: A policy for a health plan that provides coverage for health care only through contracted or employed physicians and hospitals located in particular geographic or service areas. HMOs emphasize prevention and early detection of illness. Eligibility to enroll in an HMO is determined by where a covered party lives or works.
Definition: A network-based, managed care plan that allows a covered party to choose any health care provider. However, if care is received from a "preferred" (participating in-network) provider, there are generally higher benefit coverage and lower deductibles.
A person reviews organisms of microbiology results of a given patient.
A person reviews the sensitivity test of microbiology results of a given patient.
A clinician reviews a work list of medications to be administered to a given patient.
Proposed therapy may be inappropriate or contraindicated due to patient age
Proposed therapy may be inappropriate or contraindicated due to an existing/recent patient condition or diagnosis
Description:Proposed therapy may be inappropriate or contraindicated because of a common but non-patient specific reaction to the product. Example:There is no record of a specific sensitivity for the patient, but the presence of the sensitivity is common and therefore caution is warranted.
Proposed therapy may be inappropriate or contraindicated due to patient genetic indicators.
Proposed therapy may be inappropriate or contraindicated due to patient gender.
Proposed therapy may be inappropriate or contraindicated due to recent lab test results
Proposed therapy may be inappropriate or contraindicated based on the potential for a patient reaction to the proposed product
Proposed therapy may be inappropriate or contraindicated because of a potential patient reaction to a cross-sensitivity related product.
A clinician creates a request for a laboratory test to be done for a given patient.
A clinician creates a request for the administration of one or more medications to a given patient.
Hypersensitivity to an agent caused by an immunologic response to an initial exposure
Hypersensitivity resulting in an adverse reaction upon exposure to a drug.
Hypersensitivity resulting in an adverse reaction upon exposure to environmental conditions.
Hypersensitivity resulting in an adverse reaction upon exposure to food.
A clinician enters a clinical note about a given patient
A person reviews a clinical note of a given patient.
A person reviews a list of diagnoses of a given patient.
A person reviews a list of laboratory results of a given patient.
A person reviews a list of microbiology results of a given patient.
A person reviews a list of medication orders submitted to a given patient
A person reviews a list of orders submitted to a given patient.
A person reviews a pathology report of a given patient.
A person reviews a list of problems of a given patient.
A person reviews a radiology report of a given patient.
A person reviews a Risk Assessment Instrument report of a given patient.
Definition: A public or government health program that administers and funds coverage for dental care to assist program eligible who meet financial and health status criteria.
Definition: A public or government health program that administers and funds coverage for health and social services to assist program eligible who meet financial and health status criteria related to a particular disease. Example: Reproductive health, sexually transmitted disease, and end renal disease programs.
Definition: Government administered and funded mental health program for beneficiaries meeting financial and mental health status criteria. Administration, funding levels, eligibility criteria, covered benefits, provider types, and financial participation are typically set by a regulatory process. Payer responsibilities for administering the program may be delegated to contractors. Example: In the U.S., states receive funding for substance use programs from the Substance Abuse Mental Health Administration (SAMHSA).
Definition: Government administered and funded program to support provision of care to underserved populations through safety net clinics. Example: In the U.S., safety net providers such as federally qualified health centers (FQHC) receive funding under PHSA Section 330 grants administered by the Health Resources and Services Administration.
Definition: Government administered and funded substance use program for beneficiaries meeting financial, substance use behavior, and health status criteria. Beneficiaries may be required to enroll as a result of legal proceedings. Administration, funding levels, eligibility criteria, covered benefits, provider types, and financial participation are typically set by a regulatory process. Payer responsibilities for administering the program may be delegated to contractors. Example: In the U.S., states receive funding for substance use programs from the Substance Abuse Mental Health Administration (SAMHSA).
Definition: A government health program that provides coverage for health services to persons meeting eligibility criteria such as income, location of residence, access to other coverages, health condition, and age, the cost of which is to some extent subsidized by public funds.
Proposed therapy may be inappropriate or contraindicated because of a recorded patient allergy to the proposed product. (Allergies are immune based reactions.)
Proposed therapy may be inappropriate or contraindicated because of a recorded patient intolerance to the proposed product. (Intolerances are non-immune based sensitivities.)
Description:The number of repeating elements is above the maximum number of repetitions allowed.
Description:The number of repeating elements is below the minimum number of repetitions allowed.
Definition: Consent to have de-identified healthcare information in an electronic health record that is accessed for research purposes, but without consent to re-identify the information under any circumstance.
Definition: Consent to have de-identified healthcare information in an electronic health record that is accessed for research purposes re-identified under specific circumstances outlined in the consent. Example:: Where there is a need to inform the subject of potential health issues.
A refill where the quantity supplied is equal to one full repetition of the ordered amount. (e.g. If the order was 90 tablets, 3 refills, a complete fill would be for the full 90 tablets.)
The first fill against an order that has already been filled at least once at another facility.
A refill where the quantity supplied is less than one full repetition of the ordered amount. (e.g. If the order was 90 tablets, 3 refills, a partial fill might be for only 30 tablets.)
A fill against an order that has already been filled (or partially filled) at least once and where the strength supplied is less than the ordered strength (e.g. 10mg for an order of 50mg where a subsequent fill will dispense 40mg tablets).
A fill where the remainder of a 'complete' fill is provided after a trial fill has been provided.
A refill where the quantity supplied is equal to one full repetition of the ordered amount. (e.g. If the order was 90 tablets, 3 refills, a complete fill would be for the full 90 tablets.) and where the strength supplied is less than the ordered strength (e.g. 10mg for an order of 50mg where a subsequent fill will dispense 40mg tablets).
The first fill against an order that has already been filled at least once at another facility and where the strength supplied is less than the ordered strength (e.g. 10mg for an order of 50mg where a subsequent fill will dispense 40mg tablets).
A refill where the quantity supplied is less than one full repetition of the ordered amount. (e.g. If the order was 90 tablets, 3 refills, a partial fill might be for only 30 tablets.) and where the strength supplied is less than the ordered strength (e.g. 10mg for an order of 50mg where a subsequent fill will dispense 40mg tablets).
A person reviews a Falls Risk Assessment Instrument report of a given patient.
Proposed therapy may be inappropriate or contraindicated because of a recorded patient allergy to a cross-sensitivity related product. (Allergies are immune based reactions.)
Proposed therapy may be inappropriate or contraindicated because of a recorded prior adverse reaction to a cross-sensitivity related product.
Proposed therapy may be inappropriate or contraindicated because of a recorded patient intolerance to a cross-sensitivity related product. (Intolerances are non-immune based sensitivities.)
Definition: A government health program that provides coverage through managed care contracts for health services to persons meeting eligibility criteria such as income, location of residence, access to other coverages, health condition, and age, the cost of which is to some extent subsidized by public funds. Discussion: The structure and business processes for underwriting and administering a subsidized managed care program is further specified by the Underwriter and Payer Role.class and Role.code.
Definition: A government health program that provides coverage for health services to persons meeting eligibility criteria for a supplemental health policy or program such as income, location of residence, access to other coverages, health condition, and age, the cost of which is to some extent subsidized by public funds. Example: Supplemental health coverage program may cover the cost of a health program or policy financial participations, such as the copays and the premiums, and may provide coverage for services in addition to those covered under the supplemented health program or policy. In the U.S., Medicaid programs may pay the premium for a covered party who is also covered under the Medicare program or a private health policy. Discussion: The structure and business processes for underwriting and administering a subsidized supplemental retiree health program is further specified by the Underwriter and Payer Role.class and Role.code.
A fill where the remainder of a 'complete' fill is provided after a trial fill has been provided and where the strength supplied is less than the ordered strength (e.g. 10mg for an order of 50mg where a subsequent fill will dispense 40mg tablets).
Proposed therapy may interact with an existing or recent drug therapy
Proposed therapy may interact with existing or recent natural health product therapy
Proposed therapy may interact with a non-prescription drug (e.g. alcohol, tobacco, Aspirin)
Transfer of ownership for a product for financial compensation.
Description:A local business rule relating multiple elements has been violated.
Description:The specified code is not valid against the list of codes allowed for the element.
Description:The element does not follow the formatting or type rules defined for the field.
Description:The request is missing elements or contains elements which cause it to not meet the legal standards for actioning.
Description:The length of the data specified falls out of the range defined for the element.
Description:The specified element must be specified with a non-null value under certain conditions. In this case, the conditions are true but the element is still missing or null.
Description:The specified element is mandatory and was not included in the instance.
Description:More than one element with the same value exists in the set. Duplicates not permission in this set in a set.
Description:The number of repeating elements falls outside the range of the allowed number of repetitions.
The available quantity of specimen. This is the current quantity minus any planned consumption (e.g., tests that are planned)
The quantity of specimen that is used each time the equipment uses this substance
The current quantity of the specimen, i.e., initial quantity minus what has been actually used.
The initial quantity of the specimen in inventory
These are moods describing activities as they progress in the business cycle, from defined, through planned and ordered to completed.
Any of the above service moods (e.g., event, intent, or goal) can be turned into a predicate used as a criterion to express conditionals (or queries.) However, currently we allow only criteria on service events.
A definition of a service (master). Historical note: in previous RIM versions, the definition mood was captured as a separate class hierarchy, called Master_service.
A service that actually happens, may be an ongoing service or a documentation of a past service. Historical note: in previous RIM versions, the event mood was captured as a separate class hierarchy, called Patient_service_event, and later Service_event.
An intention or plan to perform a service. Historical note: in previous RIM versions, the intent mood was captured as a separate class hierarchy, called Service_intent_or_order.
A criterion or condition over actual and potential services that must apply for an associated service to be considered. Matches records any ActMoodCompletionTrack moods.
Definition:An act that is considered likely to occur in the future. The essential feature of an act expressed in expectation mood is that it is likely to occur. An expectation may be desirable, undesirable or neutral in effect. Examples:Prognosis of a condition, Expected date of discharge from hospital, patient will likely need an emergency decompression of the intracranial pressure by morning. Discussion:INT (intent) reflects a plan for the future, which is a declaration to do something. This contrasts with expectation, which is a prediction that something will happen in the future. GOL (goal) reflects a hope rather than a prediction. RSK (risk) reflects a potential negative event that may or may not be expected to happen.
Definition:An observation that is considered to be desirable to occur in the future. The essential feature of a goal is that if it occurs it would be considered as a marker of a positive outcome or of progress towards a positive outcome. Examples:Target weight below 80Kg, Stop smoking, Regain ability to walk, goal is to administer thrombolytics to candidate patients presenting with acute myocardial infarction. Discussion: INT (intent) reflects a plan for the future, which is a declaration to do something. This contrasts with goal which doesn't represent an intention to act, merely a hope for an eventual result. A goal is distinct from the intended actions to reach that goal. "I will reduce the dose of drug x to 20mg" is an intent. "I hope to be able to get the patient to the point where I can reduce the dose of drug x to 20mg" is a goal. EXPEC (expectation) reflects a prediction rather than a hope. RSK (risk) reflects a potential negative event rather than a hope.
An option is an alternative set of property-value bindings. Options specify alternative sets of values, typically used in definitions or orders to describe alternatives. An option can only be used as a group, that is, all assigned values must be used together. Historical note: in HL7 v2.x option existed in the special case for alternative medication routes (RXR segment).
A kind of service which is authorized to be performed.
A request for authorization to perform a kind of service. This is distinct from RQO which is a request for an actual act. PERMRQ is merely a request for permission to perform an act.Discussion:
Definition:An act that may occur in the future and which is regarded as undesirable. The essential feature of a risk is that if it occurs this would be regarded as a marker of a negative outcome or of deterioration towards a negative outcome. Recording a risk indicates that it is seen as more likely to occur in the subject than in a general member of the population but does not mean it is expected to occur. Examples:Increased risk of DVT, at risk for sub-acute bacterial endocarditis. Discussion:Note: An observation in RSK mood expresses the undesirable act, and not the underlying risk factor. A risk factor that is present (e.g. obesity, smoking, etc) should be expressed in event mood. INT (intent) reflects a plan for the future, which is a declaration to do something. This contrasts with RSK (risk), which is the potential that something negative will occur that may or may not ever happen. GOL (goal) reflects a hope to achieve something. EXPEC (expectation) is the prediction of a positive or negative event. This contrasts with RSK (risk), which is the potential that something negative will occur that may or may not ever happen, and may not be expected to happen.
A criterion or condition over service events that must apply for an associated service to be considered.
A planned Act for a specific time and place.
A request for the booking of an appointment.
A request or order for a service is an intent directed from a placer (request author) to a fulfiller (service performer). Rationale: The concepts of a "request" and an "order" are viewed as different, because there is an implication of a mandate associated with order. In practice, however, this distinction has no general functional value in the inter-operation of health care computing. "Orders" are commonly refused for a variety of clinical and business reasons, and the notion of a "request" obligates the recipient (the fulfiller) to respond to the sender (the author). Indeed, in many regions, including Australia and Europe, the common term used is "request." Thus, the concept embodies both notions, as there is no useful distinction to be made. If a mandate is to be associated with a request, this will be embodied in the "local" business rules applied to the transactions. Should HL7 desire to provide a distinction between these in the future, the individual concepts could be added as specializations of this concept. The critical distinction here, is the difference between this concept and an "intent", of which it is a specialization. An intent involves decisions by a single party, the author. A request, however, involves decisions by two parties, the author and the fulfiller, with an obligation on the part of the fulfiller to respond to the request indicating that the fulfiller will indeed fulfill the request.
An intent to perform a service that has the strength of a commitment, i.e., other parties may rely on the originator of such promise that said originator will see to it that the promised act will be fulfilled. A promise can be either solicited or unsolicited.
A non-mandated intent to perform an act. Used to record intents that are explicitly not Orders. Professional responsibility for the 'proposal' may or may not be present.
Periods of time on a schedule for a resource. Appointments occupy sets of one or more booked slots. A slot that is open for appointments is considered available and a slot that is held back for administrative purposes is considered blocked. A Resource slot that is "tentatively" booked is referred to as reserved.
A non-mandated intent to perform an act where a level of professional responsibility is being accepted by making the proposal.
Codes representing the defined possible states of an Act, as defined by the Act class state machine.
Encompasses the expected states of an Act, but excludes "nullified" and "obsolete" which represent unusual terminal states for the life-cycle.
This Act instance was created in error and has been 'removed' and is treated as though it never existed. A record is retained for audit purposes only.
This Act instance has been replaced by a new instance.
The Act has been terminated prior to the originally intended completion.
The Act can be performed or is being performed
The Act has been abandoned before activation.
An Act that has terminated normally after all of its constituents have been performed.
An Act that is still in the preparatory stages has been put aside. No action can occur until the Act is released.
An Act that is in the preparatory stages and may not yet be acted upon
An Act that has been activated (actions could or have been performed against it), but has been temporarily disabled. No further action should be taken against it until it is released
The gender of a person used for adminstrative purposes (as opposed to clinical gender)
The gender of a person could not be uniquely defined as male or female, such as hermaphrodite.
Classifies the Entity class and all of its subclasses. The terminology is hierarchical. At the top is this HL7-defined domain of high-level categories (such as represented by the Entity subclasses). Each of these terms must be harmonized and is specializable. The value sets beneath are drawn from multiple, frequently external, domains that reflect much more fine-grained typing.
A type of container that can hold other containers or other holders.
A physical artifact that stores information about the granting of authorization.
Class to contain unique attributes of diagnostic imaging equipment.
A health chart included to serve as a document receiving entity in the management of medical records.
Anything that essentially has the property of life, independent of current state (a dead human corpse is still essentially a living subject).
Any thing that has extension in space and mass, may be of living or non-living origin.
A social or legal structure formed by human beings.
A physical place or site with its containing structure. May be natural or man-made. The geographic position of a place may or may not be constant.
A grouping of resources (personnel, material, or places) to be used for scheduling purposes. May be a pool of like-type resources, a team, or combination of personnel, material and places.
A living subject of the species homo sapiens.
A substance that is fully defined by an organic or inorganic chemical formula, includes mixtures of other chemical substances. Refine using, e.g., IUPAC codes.
Naturally occurring, processed or manufactured entities that are primarily used as food for humans and animals.
Corresponds to the ManufacturedMaterial class
A subtype of ManufacturedMaterial used in an activity, without being substantially changed through that activity. The kind of device is identified by the code attribute inherited from Entity. Usage: This includes durable (reusable) medical equipment as well as disposable equipment.
A living subject from the animal kingdom.
All single celled living organisms including protozoa, bacteria, yeast, viruses, etc.
A living subject from the order of plants.
An agency of the people of a state often assuming some authority over a certain matter. Includes government, governmental agencies, associations.
A politically organized body of people bonded by territory, culture, or ethnicity, having sovereignty (to a certain extent) granted by other states (enclosing or neighboring states). This includes countries (nations), provinces (e.g., one of the United States of America or a French departement), counties or municipalities. Refine using, e.g., ISO country codes, FIPS-PUB state codes, etc.
The territory of a city, town or other municipality.
The territory of a county, parish or other division of a state or province.
The territory of a state, province, department or other division of a sovereign country.
A politically organized body of people bonded by territory and known as a nation.
EntityDeterminer in natural language grammar is the class of words that comprises articles, demonstrative pronouns, and quantifiers. In the RIM, determiner is a structural code in the Entity class to distinguish whether any given Entity object stands for some, any one, or a specific thing.
The specific determiner indicates that the given Entity is taken as one specific thing instance. For example, a human INSTANCE (quantity = 1,) stands for exactly one human being.
The described determiner is used to indicate that the given Entity is taken as a general description of a kind of thing that can be taken in whole, in part, or in multiples.
The described quantified determiner indicates that the given Entity is taken as a general description of a specific amount of a thing. For example, QUANTIFIED_KIND of syringe (quantity = 3,) stands for exactly three syringes.
Marriage contract has been declared null and to not have existed
Marriage contract has been declared dissolved and inactive
No marriage contract has ever been entered
Person declares that a domestic partner relationship exists.
No information whatsoever can be inferred from this exceptional value. This is the most general exceptional value. It is also the default exceptional value.
Value is not present in a message. This is only defined in messages, never in application data! All values not present in the message must be replaced by the applicable default, or no-information (NI) as the default of all defaults.
Information is not available at this time but it is expected that it will be available later.
There is information on this item available but it has not been provided by the sender due to security, privacy or other reasons. There may be an alternate mechanism for gaining access to this information. Note: using this null flavor does provide information that may be a breach of confidentiality, even though no detail data is provided. Its primary purpose is for those circumstances where it is necessary to inform the receiver that the information does exist without providing any detail.
Known to have no proper value (e.g., last menstrual period for a male).
The actual value is not an element in the value domain of a variable. (e.g., concept not provided by required code system).
Definition: The actual value has not yet been encoded within the approved valueset for the domain. Example: Original text or a local code has been specified but translation or encoding to the approved valueset has not yet occurred. Usage Notes: If it is known that it is not possible to encode the concept, OTH should be used instead.
A proper value is applicable, but not known.
Information was sought but not found (e.g., patient was asked but didn't know)
This information has not been sought (e.g., patient was not asked)
The specific quantity is not known, but is known to be non-zero and is not specified because it makes up the bulk of the material. 'Add 10mg of ingredient X, 50mg of ingredient Y, and sufficient quantity of water to 100mL.' The null flavor would be used to express the quantity of water.
The content is greater than zero, but too small to be quantified.