| RCMR_HD000050UV02 Medical Records HMD |
Description: This RMIM is used to derive Medical Records specifications. (Link to Excel View) Derived from RMIM: RCMR_RM000050UV02 |
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| ClinicalDocument | |||||||||
| classCode [1..1] (M) Act (CS) {CNE:V:ActClassClinicalDocument, root= "DOCCLIN"} |
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| moodCode [1..1] (M) Act (CS) {CNE:V:ActMoodEventOccurrence, root= "EVN"} |
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| id [1..1] Act (II) |
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| code [1..1] Act (CD) {CWE:D:DocumentType} |
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| title [0..1] Act (ST) |
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| text [0..1] Act (ED) |
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| statusCode [1..1] Act (CS) {CNE:D:ActStatus} |
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| effectiveTime [1..1] Act (TS) |
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| availabilityTime [0..1] Act (TS) |
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| confidentialityCode [1..1] Act (CD) {CWE:V:x_BasicConfidentialityKind} |
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| reasonCode [0..1] Act (CD) {CWE:D:ActReason} |
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| languageCode [0..1] Act (CD) {CNE:D:HumanLanguage} |
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| setId [0..1] ContextStructure (II) |
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| versionNumber [0..1] ContextStructure (INT) |
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| completionCode [0..1] Document (CD) {CWE:D:DocumentCompletion} |
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| storageCode [0..1] Document (CD) {CWE:D:DocumentStorage} |
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| copyTime [0..1] Document (TS) |
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| subject [0..*] (Subject) | |||||||||
| recordTarget [1..*] (RecordTarget) | |||||||||
| author [1..*] (Author) | |||||||||
| dataEnterer [0..1] (DataEnterer) | |||||||||
| custodian [1..1] (Custodian) | |||||||||
| informationRecipient [0..*] (InformationRecipient) | |||||||||
| legalAuthenticator [0..1] (LegalAuthenticator) | |||||||||
| authenticator [0..*] (Authenticator) | |||||||||
| participation [0..*] (Participant1) | |||||||||
| inFulfillmentOf [0..*] (InFulfillmentOf) | |||||||||
| documentationOf [0..*] (DocumentationOf) | |||||||||
| relatedDocument [0..*] (RelatedDocument) | |||||||||
| authorization [0..*] (Authorization) | |||||||||
| componentOf [0..1] (Component1) | |||||||||
| Subject | |||||||||
| typeCode [1..1] (M) Participation (CS) {CNE:V:ParticipationTargetSubject, root= "SBJ"} |
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| relatedSubject [1..1] (RelatedSubject) | |||||||||
| RelatedSubject | |||||||||
| classCode [1..1] (M) Role (CS) {CNE:V:x_DocumentSubject} |
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| code [0..1] Role (CD) {CWE:D:PersonalRelationshipRoleType} |
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| addr [0..*] Role (DSET<AD>) |
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| telecom [0..*] Role (LIST<TEL>) |
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| subject [0..1] (SubjectPerson) | |||||||||
| SubjectPerson | |||||||||
| classCode [1..1] (M) Entity (CS) {CNE:V:EntityClassPerson, root= "PSN"} |
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| determinerCode [1..1] (M) Entity (CS) {CNE:V:EntityDeterminerSpecific, root= "INSTANCE"} |
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| name [0..*] Entity (DSET<PN>) |
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| administrativeGenderCode [0..1] LivingSubject (CD) {CWE:D:AdministrativeGender} |
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| birthTime [0..1] LivingSubject (TS) |
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| RecordTarget | |||||||||
| typeCode [1..1] (M) Participation (CS) {CNE:V:ParticipationRecordTarget, root= "RCT"} |
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| patient [1..1] (R_PatientUniversal) | |||||||||
| Author | |||||||||
| typeCode [1..1] (M) Participation (CS) {CNE:V:ParticipationAuthorOriginator, root= "AUT"} |
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| functionCode [0..1] Participation (CD) {CWE:D:ParticipationFunction} |
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| time [1..1] Participation (TS) |
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| assignedAuthor [1..1] (AssignedAuthor) | |||||||||
| AssignedAuthor | |||||||||
| classCode [1..1] (M) Role (CS) {CNE:V:RoleClassAssignedEntity, root= "ASSIGNED"} |
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| id [1..*] Role (DSET<II>) |
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| code [0..1] Role (CD) {CWE:D:RoleCode} |
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| addr [0..*] Role (DSET<AD>) |
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| telecom [0..*] Role (DSET<TEL>) |
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| assignedAuthorChoice [0..1] (AuthorChoice) | |||||||||
| representedOrganization [0..1] (E_OrganizationUniversal) | |||||||||
| AuthorChoice | |||||||||
| choice of Person | |||||||||
| or AuthoringDevice | |||||||||
| Person | |||||||||
| classCode [1..1] (M) Entity (CS) {CNE:V:EntityClassPerson, root= "PSN"} |
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| determinerCode [1..1] (M) Entity (CS) {CNE:V:EntityDeterminerSpecific, root= "INSTANCE"} |
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| name [0..*] Entity (DSET<PN>) |
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| AuthoringDevice | |||||||||
| classCode [1..1] (M) Entity (CS) {CNE:V:EntityClassDevice, root= "DEV"} |
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| determinerCode [1..1] (M) Entity (CS) {CNE:V:EntityDeterminerSpecific, root= "INSTANCE"} |
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| code [0..1] Entity (CD) {CWE:D:EntityCode} |
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| manufacturerModelName [0..1] Device (SC) |
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| softwareName [0..1] Device (SC) |
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| DataEnterer | |||||||||
| typeCode [1..1] (M) Participation (CS) {CNE:V:ParticipationDataEntryPerson, root= "ENT"} |
Design Comments: e.g. transcriptionist |
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| time [0..1] Participation (TS) |
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| assignedPerson [1..1] (R_AssignedPersonUniversal) | |||||||||
| Custodian | |||||||||
| typeCode [1..1] (M) Participation (CS) {CNE:V:ParticipationCustodian, root= "CST"} |
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| assignedCustodian [1..1] (AssignedCustodian) | |||||||||
| AssignedCustodian | |||||||||
| classCode [1..1] (M) Role (CS) {CNE:V:RoleClassAssignedEntity, root= "ASSIGNED"} |
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| representedOrganization [1..1] (E_OrganizationUniversal) | |||||||||
| InformationRecipient | |||||||||
| typeCode [1..1] (M) Participation (CS) {CNE:V:x_InformationRecipient} |
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| intendedRecipient [1..1] (IntendedRecipient) | |||||||||
| IntendedRecipient | |||||||||
| classCode [1..1] (M) Role (CS) {CNE:V:x_InformationRecipientRole} |
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| id [0..*] Role (DSET<II>) |
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| addr [0..*] Role (DSET<AD>) |
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| telecom [0..*] Role (DSET<TEL>) |
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| informationRecipient [0..1] (Person) | |||||||||
| receivedOrganization [0..1] (E_OrganizationUniversal) | |||||||||
| LegalAuthenticator | |||||||||
| typeCode [1..1] (M) Participation (CS) {CNE:V:ParticipationLegalAuthenticator, root= "LA"} |
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| time [0..1] Participation (TS) |
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| signatureCode [1..1] Participation (CS) {CNE:D:ParticipationSignature} |
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| assignedPerson [1..1] (R_AssignedPersonUniversal) | |||||||||
| Authenticator | |||||||||
| typeCode [1..1] (M) Participation (CS) {CNE:V:ParticipationAuthenticator, root= "AUTHEN"} |
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| time [0..1] Participation (TS) |
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| signatureCode [1..1] Participation (CS) {CNE:D:ParticipationSignature} |
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| assignedPerson [1..1] (R_AssignedPersonUniversal) | |||||||||
| Participant1 | |||||||||
| typeCode [1..1] (M) Participation (CS) {CNE:D:ParticipationType} |
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| functionCode [0..1] Participation (CD) {CWE:D:ParticipationFunction} |
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| time [0..1] Participation (IVL<TS>) |
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| associatedEntity [1..1] (AssociatedEntity) | |||||||||
| AssociatedEntity | |||||||||
| classCode [1..1] (M) Role (CS) {CNE:V:RoleClassAssociative} |
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| id [0..*] Role (DSET<II>) |
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| code [0..1] Role (CD) {CWE:D:RoleCode} |
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| addr [0..*] Role (DSET<AD>) |
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| telecom [0..*] Role (DSET<TEL>) |
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| associatedPerson [0..1] (Person) | |||||||||
| scopingOrganization [0..1] (E_OrganizationUniversal) | |||||||||
| InFulfillmentOf | |||||||||
| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:ActRelationshipFulfills, root= "FLFS"} |
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| order [1..1] (Order) | |||||||||
| Order | |||||||||
| classCode [1..1] (M) Act (CS) {CNE:V:ActClassRoot, root= "ACT"} |
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| moodCode [1..1] (M) Act (CS) {CNE:V:ActMoodRequest, root= "RQO"} |
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| id [1..*] Act (DSET<II>) |
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| code [0..1] Act (CD) {CWE:D:ActCode} |
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| priorityCode [0..1] Act (CD) {CWE:D:ActPriority} |
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| DocumentationOf | |||||||||
| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:ActRelationshipDocuments, root= "DOC"} |
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| serviceEvent [1..1] (ServiceEvent) | |||||||||
| ServiceEvent | |||||||||
| classCode [1..1] (M) Act (CS) {CNE:V:ActClassRoot, root= "ACT"} |
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| moodCode [1..1] (M) Act (CS) {CNE:V:ActMoodEventOccurrence, root= "EVN"} |
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| id [0..*] Act (DSET<II>) |
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| code [0..1] Act (CD) {CWE:D:ActCode} |
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| effectiveTime [0..1] Act (IVL<TS>) |
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| performer [0..*] (Performer1) | |||||||||
| Performer1 | |||||||||
| typeCode [1..1] (M) Participation (CS) {CNE:V:x_ServiceEventPerformer} |
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| functionCode [0..1] Participation (CD) {CWE:D:ParticipationFunction} |
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| time [0..1] Participation (IVL<TS>) |
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| assignedPerson [1..1] (R_AssignedPersonUniversal) | |||||||||
| RelatedDocument | |||||||||
| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:x_ActRelationshipDocument} |
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| parentDocument [1..1] (ParentDocument) | |||||||||
| ParentDocument | |||||||||
| classCode [1..1] (M) Act (CS) {CNE:V:ActClassClinicalDocument, root= "DOCCLIN"} |
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| moodCode [1..1] (M) Act (CS) {CNE:V:ActMoodEventOccurrence, root= "EVN"} |
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| id [1..*] Act (DSET<II>) |
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| code [0..1] Act (CD) {CWE:D:DocumentType} |
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| text [0..1] Act (ED) |
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| setId [0..1] ContextStructure (II) |
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| versionNumber [0..1] ContextStructure (INT) |
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| Authorization | |||||||||
| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:ActRelationshipAuthorizedBy, root= "AUTH"} |
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| consent [1..1] (Consent) | |||||||||
| Consent | |||||||||
| classCode [1..1] (M) Act (CS) {CNE:V:ActClassConsent, root= "CONS"} |
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| moodCode [1..1] (M) Act (CS) {CNE:V:ActMoodEventOccurrence, root= "EVN"} |
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| id [0..*] Act (DSET<II>) |
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| code [0..1] Act (CD) {CWE:D:ActCode} |
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| statusCode [1..1] Act (CS) {CNE:C:ActStatus:completed} |
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| Component1 | |||||||||
| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:ActRelationshipHasComponent, root= "COMP"} |
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| encompassingEncounter [1..1] (EncompassingEncounter) | |||||||||
| EncompassingEncounter | |||||||||
| classCode [1..1] (M) Act (CS) {CNE:V:ActClassEncounter, root= "ENC"} |
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| moodCode [1..1] (M) Act (CS) {CNE:V:ActMoodEventOccurrence, root= "EVN"} |
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| id [0..*] Act (DSET<II>) |
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| code [0..1] Act (CD) {CWE:V:ActEncounterCode} |
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| effectiveTime [1..1] Act (IVL<TS>) |
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| dischargeDispositionCode [0..1] PatientEncounter (CD) {CWE:D:EncounterDischargeDisposition} |
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| encounterParticipant [0..*] (EncounterParticipant) | |||||||||
| location [0..1] (Location) | |||||||||
| EncounterParticipant | |||||||||
| typeCode [1..1] (M) Participation (CS) {CNE:V:x_EncounterParticipant} |
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| time [0..1] Participation (IVL<TS>) |
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| assignedPerson [1..1] (R_AssignedPersonUniversal) | |||||||||
| Location | |||||||||
| typeCode [1..1] (M) Participation (CS) {CNE:V:ParticipationTargetLocation, root= "LOC"} |
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| healthCareFacility [1..1] (HealthCareFacility) | |||||||||
| HealthCareFacility | |||||||||
| classCode [1..1] (M) Role (CS) {CNE:V:RoleClassServiceDeliveryLocation, root= "SDLOC"} |
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| id [0..*] Role (DSET<II>) |
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| code [0..1] Role (CD) {CWE:V:ServiceDeliveryLocationRoleType} |
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| location [0..1] (Place) | |||||||||
| serviceProviderOrganization [0..1] (E_OrganizationUniversal) | |||||||||
| Place | |||||||||
| classCode [1..1] (M) Entity (CS) {CNE:V:EntityClassPlace, root= "PLC"} |
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| determinerCode [1..1] (M) Entity (CS) {CNE:V:EntityDeterminerSpecific, root= "INSTANCE"} |
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| name [0..1] Entity (EN) |
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| addr [0..1] Place (AD) |
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