| PRPA_HD401001UV02 Active Ambulatory Encounter |
(Link to Excel View) Derived from RMIM: PRPA_RM401001UV02 |
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| AmbulatoryEncounterEvent |
Design Comments: An interaction between a patient and care provider(s) for the purpose of providing healthcare-related service(s). This is an ambulatory encounter characterized by the patient visiting a healthcare facility for diagnosis or treatment not requiring an overnight stay. |
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| classCode [1..1] (M) PatientEncounter (CS) {CNE:V:ActClassEncounter, root= "ENC"} |
Design Comments: Structural attribute; this is a "patient encounter" act |
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| moodCode [1..1] (M) PatientEncounter (CS) {CNE:V:ActMoodEventOccurrence, root= "EVN"} |
Design Comments: Structural attribute; this is a patient encounter event |
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| id [1..*] (M) PatientEncounter (DSET<II>) |
Design Comments: One or more unique identifiers for this encounter (for example, an "internal" id used only by computer systems and an "external" id for display to users) |
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| code [1..1] (M) PatientEncounter (CD) {CWE:D:ActEncounterAmbulatoryType} |
Design Comments: A value further specifying the type of patient encounter. This is constrained to "ambulatory". |
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| statusCode [1..1] (M) PatientEncounter (CS) {CNE:V:ActStatusActive} |
Design Comments: A value specifying the state of this patient encounter; this encounter is in the 'active' state |
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| effectiveTime [1..1] PatientEncounter (IVL<TS>) |
Design Comments: The time interval starting with the administrative onset of the encounter (e.g. admission, registration, patient arrival) and ending with the patient's departure (e.g. discharge). Note, for active encounters the end of the effectiveTime range is the anticipated end date-time. |
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| activityTime [0..1] PatientEncounter (IVL<TS>) |
Design Comments: The total time interval for this encounter including preparation before the patient arrives and clean-up actions after the patient departs |
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| priorityCode [0..1] PatientEncounter (CD) {CWE:D:X_EncounterAdmissionUrgency} |
Design Comments: A value representing the urgency for the encounter |
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| confidentialityCode [0..*] PatientEncounter (DSET<CD>) {CWE:D:Confidentiality} |
Design Comments: Value(s) that control the disclosure of information about this patient encounter |
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| reasonCode [0..*] PatientEncounter (DSET<CD>) {CWE:D:X_ActEncounterReason} |
Design Comments: A set of values specifying the administrative reasons for this encounter. Examples are "Medical Necessity", "Patient's Request" and "Dependency". Note, medical reason(s) for the encounter are specified as associated diagnoses. |
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| admissionReferralSourceCode [0..1] PatientEncounter (CD) {CWE:D:EncounterReferralSource} |
Design Comments: A value categorizing the type of place or organization responsible for the patient immediately prior to this encounter. Note: in the US realm this references the UB92 FL 20 - Source of Admission value set. |
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| lengthOfStayQuantity [0..1] PatientEncounter (PQ.TIME) |
Design Comments: The expected or actual quantity of time for the patient encounter. While the encounter is still "active" (the encounter does not have an end date yet) this field should be interpreted as the expected length. When the encounter is "completed" this field contains the actual length of stay. The actual quantity cannot be simply calculated from the start and end dates because of possible leaves of absence. |
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| dischargeDispositionCode [0..1] PatientEncounter (CD) {CWE:D:EncounterDischargeDisposition} |
Design Comments: A code depicting the disposition of the patient at the time of discharge (e.g., discharged to home, expired, against medical advice, etc.). While the encounter is still "active" (the encounter does not have an end date yet) this attribute should be interpreted as the expected discharge disposition. When the encounter is "completed" this attribute contains the actual discharge disposition. Note: in the US realm this references the UB92 FL 22 - Patient Status value set. |
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| preAdmitTestInd [0..1] PatientEncounter (BL) |
Design Comments: Indicates whether tests were done in a preadmission encounter prior to this encounter. Note: the actual encounter for the pre-admit tests can be related to the encounter with the reasonOf act relationship |
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| specialCourtesiesCode [0..*] PatientEncounter (DSET<CD>) {CWE:D:EncounterSpecialCourtesy} |
Design Comments: A set of values identifying special courtesies extended to the patient for this encounter (e.g., no courtesies, extended courtesies, professional courtesy, VIP courtesies). |
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| specialArrangementCode [0..*] PatientEncounter (DSET<CD>) {CWE:D:SpecialArrangement} |
Design Comments: A set of values representing the types of special arrangements provided for this patient encounter (e.g., wheelchair, stretcher, interpreter, attendant, seeing eye dog) |
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| subject [1..1] (Subject) |
Design Comments: The patient (living subject) in the role of patient is the subject of a care provision act. The care provision performer may be the primary provider responsible for general care or within a specific healthcare facility. This relationship is usually solid over time and is recorded only for administrative purposes; actual care provided by a healthcare provider is recorded elsewhere. |
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| responsibleParty [0..1] (ResponsibleParty) |
Design Comments: An association to a healthcare provider organization that holds clinical responsibility for the patient encounter |
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| admitter [0..1] (Admitter) |
Design Comments: An association to a healthcare practitioner who required/authorized this patient encounter |
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| attender [0..1] (Attender) |
Design Comments: An association to a healthcare practitioner who has responsibility for overseeing a patient's care during a patient encounter |
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| referrer [0..1] (Referrer) |
Design Comments: An association to a healthcare practitioner who requested that a patient encounter take place |
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| consultant [0..*] (Consultant) |
Design Comments: An association to an advisor participating in a patient encounter by performing evaluations and making recommendations |
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| notificationContact [0..*] (NotificationContact) |
Design Comments: An association to a patient's designated emergency contact for a patient encounter |
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| location [0..*] (Location1) |
Design Comments: An association to a patient's assigned location during a patient encounter. |
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| inFulfillmentOf [0..1] (InFulfillmentOf) |
Design Comments: An association of a patient encounter to the appointment that scheduled it |
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| sequelTo [0..1] (SequelTo) |
Design Comments: Association to a previous encounter for the same patient. Examples include: (1) a patient in an inpatient encounter is admitted as an inpatient after an evaluation of the seriousness of the patient's condition, (2) an inpatient is discharged from an inpatient encounter directly to an inpatient encounter as part of the same episode of care, (3) a patient is re-admitted to a healthcare facility. |
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| reason [0..*] (Reason1) |
Design Comments: Association to a diagnosis observation. Each diagnosis is sent in a separate A_ObservationDx CMET. The type of diagnosis is determined by the Observation.code within the A_ObservationDx CMET; "ADMX" for an admission diagnosis, "INTDX" for an interim diagnosis, and "DISDX" for a discharge diagnosis. |
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| authorization [0..*] (Authorization) |
Design Comments: Association to a consent granted by the patient or patient's representative authorizing the focal encounter. Each consent is sent in a separate A_Consent CMET. Note, this is currently a placeholder CMET until the Medical Records TC completes work on medico-legal document modeling. |
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| reference [0..*] (Reference) |
Design Comments: An optional association to one or more patient accounts. Each account with its associated account holder (guarantor) is sent in a separate A_AccountGuarantor CMET. |
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| itemStorage [0..*] (ItemStorage) |
Design Comments: Association to a report of patient valuables stored during the patient encounter. The report is sent as a free text observation of the valuables and where they are stored during the encounter. |
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| arrivedBy [0..1] (ArrivedBy) |
Design Comments: Association of a patient encounter to information about the patient's arrival at the site of the patient encounter |
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| departedBy [0..1] (DepartedBy) |
Design Comments: Association of a patient encounter to information about the patient's departure from the site of the patient encounter |
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| reasonOf [0..*] (Reason2) |
Design Comments: An optional association linking a pre-admission patient encounter (source) for tests or other preparation to the focal encounter (target) that is required the pre-admission encounter. Note that the focal encounter should have the preAdmitTestInd attribute set to "true". Both encounters will have the same subject (patient). |
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| componentOf [0..1] (Component) |
Design Comments: An optional association from the focal encounter (target) to an overall care event (source) of which it is a component. The care event represents someone (generally a health care practitioner) taking responsibility for some aspect of a patient's health; examples include primary/preferred care provider, case manager. UsageNotes: Associates an encounter with an overall Care Event |
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| Subject |
Design Comments: The patient (living subject) in the role of patient is the subject of a care provision act. The care provision performer may be the primary provider responsible for general care or within a specific healthcare facility. This relationship is usually solid over time and is recorded only for administrative purposes; actual care provided by a healthcare provider is recorded elsewhere. |
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| typeCode [1..1] (M) Participation (CS) {CNE:V:ParticipationTargetSubject, root= "SBJ"} |
Design Comments: Structural attribute; this is a "ParticipationTargetSubject" participation |
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| contextControlCode [1..1] (M) Participation (CS) {CNE:V:ContextControl, default= "OP"} |
Design Comments: A value describing how subject participation contributes to the conductible context of the focal encounter and whether it may be propagated to descendant Acts. The default is that it overwrites any inherited subject and propagates from the focal encounter to any descendant acts that allow such propagation. |
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| patient [1..1] (R_PatientIdentified-confirmable) | |||||||||
| ResponsibleParty |
Design Comments: An association to a healthcare provider organization that holds clinical responsibility for the patient encounter |
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| typeCode [1..1] (M) ManagedParticipation (CS) {CNE:V:ParticipationResponsibleParty, root= "RESP"} |
Design Comments: Structural attribute; this is a "responsibility" participation |
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| contextControlCode [1..1] (M) ManagedParticipation (CS) {CNE:V:ContextControl, default= "ON"} |
Design Comments: A value describing how responsible party participation contributes to the conductible context of the focal encounter and whether it may be propagated to descendant Acts. The default is that it overwrites any inherited responsible party and does not propagate to any acts associated with the focal encounter. |
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| time [1..1] ManagedParticipation (IVL<TS>) |
Design Comments: An interval of time specifying the period this assigned organization holds clinical responsibility for the patient encounter |
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| id [0..*] ManagedParticipation (DSET<II>) |
Design Comments: Identifier(s) for this responsible organization participation |
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| statusCode [0..1] ManagedParticipation (CS) {CNE:V:ManagedParticipationStatus} |
Design Comments: A value representing the state of the responsible organization participation (based on the RIM Managed Participation class state-machine), for example pending, active, completed. Note: only one responsibleParty participation in an encounter should be in the active state at a time. |
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| assignedOrganization [1..1] (R_AssignedOrganizationUniversal) | |||||||||
| Admitter |
Design Comments: An association to a healthcare practitioner who required/authorized this patient encounter |
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| typeCode [1..1] (M) Participation (CS) {CNE:V:ParticipationAdmitter, root= "ADM"} |
Design Comments: Structural attribute, this is an "admitter" participation |
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| contextControlCode [1..1] (M) Participation (CS) {CNE:V:ContextControl, default= "ON"} |
Design Comments: A value describing how admitter participation contributes to the conductible context of the focal encounter and whether it may be propagated to descendant Acts. The default is that it overwrites any inherited admitter and does not propagate to any acts associated with the focal encounter. |
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| time [1..1] Participation (IVL<TS>) |
Design Comments: An interval of time specifying the period this healthcare practitioner was actively involved in authorizing this patient encounter |
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| modeCode [0..1] Participation (CD) {CWE:D:ParticipationMode} |
Design Comments: A code specifying the modality by which the healthcare practitioner authorized this patient encounter. Examples include physically present, over the telephone, written communication. |
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| assignedPerson [1..1] (R_AssignedPersonUniversal) | |||||||||
| Attender |
Design Comments: An association to a healthcare practitioner who has responsibility for overseeing a patient's care during a patient encounter |
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| typeCode [1..1] (M) ManagedParticipation (CS) {CNE:V:ParticipationAttender, root= "ATND"} |
Design Comments: Structural attribute; this is an "attender" participation |
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| contextControlCode [1..1] (M) ManagedParticipation (CS) {CNE:V:ContextControl, default= "ON"} |
Design Comments: A value describing how attender participation contributes to the conductible context of the focal encounter and whether it may be propagated to descendant Acts. The default is that it overwrites any inherited attender and does not propagate to any acts associated with the focal encounter. |
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| time [1..1] ManagedParticipation (IVL<TS>) |
Design Comments: An interval of time specifying the period this practitioner has responsibility for overseeing a patient's care during a patient encounter |
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| modeCode [0..1] ManagedParticipation (CD) {CWE:D:ParticipationMode} |
Design Comments: A code specifying the modality by which the practitioner participated in this patient encounter as attender. Examples include physically present, over the telephone, written communication. |
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| id [0..*] ManagedParticipation (DSET<II>) |
Design Comments: Identifier(s) for this attender participation |
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| statusCode [0..1] ManagedParticipation (CS) {CNE:V:ManagedParticipationStatus} |
Design Comments: A value representing the state of this attender participation (based on the RIM Managed Participation class state-machine), for example pending, active, completed. |
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| assignedPerson [1..1] (R_AssignedPersonUniversal) | |||||||||
| Referrer |
Design Comments: An association to a healthcare practitioner who requested that a patient encounter take place |
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| typeCode [1..1] (M) Participation (CS) {CNE:V:ParticipationReferrer, root= "REF"} |
Design Comments: Structural attribute; this is a "referrer" participation |
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| contextControlCode [1..1] (M) Participation (CS) {CNE:V:ContextControl, default= "ON"} |
Design Comments: A value describing how referrer participation contributes to the conductible context of the focal encounter and whether it may be propagated to descendant Acts. The default is that it overwrites any inherited referrer and does not propagate to any acts associated with the focal encounter. |
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| modeCode [0..1] Participation (CD) {CWE:D:ParticipationMode} |
Design Comments: A code specifying the modality by which this practitioner participated in this patient encounter as referrer. Examples include physically present, over the telephone, written communication. |
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| assignedEntity [1..1] (R_AssignedEntityUniversal) | |||||||||
| Consultant |
Design Comments: An association to an advisor participating in a patient encounter by performing evaluations and making recommendations |
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| typeCode [1..1] (M) Participation (CS) {CNE:V:ParticipationConsultant, root= "CON"} |
Design Comments: Structural attribute; this is a "consultant" participation |
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| contextControlCode [1..1] (M) Participation (CS) {CNE:V:ContextControl, default= "ON"} |
Design Comments: A value describing how consultant participation contributes to the conductible context of the focal encounter and whether it may be propagated to descendant Acts. The default is that it overwrites any inherited consultant and does not propagate to any acts associated with the focal encounter. |
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| time [1..1] Participation (IVL<TS>) |
Design Comments: An interval of time specifying the period this practitioner was actively participating in this patient encounter by performing evaluations and making recommendations |
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| modeCode [0..1] Participation (CD) {CWE:D:ParticipationMode} |
Design Comments: A code specifying the modality by which the practitioner participated in this patient encounter as a consultant. Examples include physically present, over the telephone, written communication. |
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| assignedPerson [1..1] (R_AssignedPersonUniversal) | |||||||||
| NotificationContact |
Design Comments: An association to a patient's designated emergency contact for a patient encounter |
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| typeCode [1..1] (M) Participation (CS) {CNE:V:ParticipationUgentNotificationContact, root= "NOT"} |
Design Comments: Structural attribute; this is a "notification contact" participation |
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| contextControlCode [1..1] (M) Participation (CS) {CNE:V:ContextControl, default= "ON"} |
Design Comments: A value describing how notification contact participation contributes to the conductible context of the focal encounter and whether it may be propagated to descendant Acts. The default is that it overwrites any inherited notification contact and does not propagate to any acts associated with the focal encounter. |
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| time [0..1] Participation (IVL<TS>) |
Design Comments: An interval of time specifying the period this notification party is the patient's emergency contact. Note, this only needed if a notification party is not the patient's emergency contact for duration of the patient encounter. |
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| notificationParty [1..1] (R_NotificationPartyContact) | |||||||||
| Location1 |
Design Comments: An association to a patient's assigned location during a patient encounter. |
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| typeCode [1..1] (M) ManagedParticipation (CS) {CNE:V:ParticipationTargetLocation, root= "LOC"} |
Design Comments: Structural attribute; this is a "location" participation |
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| contextControlCode [1..1] (M) ManagedParticipation (CS) {CNE:V:ContextControl, default= "ON"} |
Design Comments: A value describing how location participation contributes to the conductible context of the focal encounter and whether it may be propagated to descendant Acts. The default is that it overwrites any inherited location and does not propagate to any acts associated with the focal encounter. |
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| time [1..1] ManagedParticipation (IVL<TS>) |
Design Comments: An interval of time specifying the period the patient is assigned to this location |
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| id [0..*] ManagedParticipation (DSET<II>) |
Design Comments: Identifier(s) for this patient location assignment |
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| statusCode [1..1] ManagedParticipation (CS) {CNE:V:ManagedParticipationStatus} |
Design Comments: A value representing the state of this patient location assignment (based on the RIM Managed Participation class state-machine), for example pending, active, completed. Note: only one location participation in an encounter should be in the active state at a time. |
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| serviceDeliveryLocation [1..1] (ServiceDeliveryLocation) |
Design Comments: A role played by a place at which services may be provided. Note that a single physical place can play multiple service delivery location roles each with its own attributes. For example, a Podiatry clinic and Research clinic may meet on alternate days in the same physical location; each clinic uses its own mailing address and telephone number. |
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| ServiceDeliveryLocation |
Design Comments: A role played by a place at which services may be provided. Note that a single physical place can play multiple service delivery location roles each with its own attributes. For example, a Podiatry clinic and Research clinic may meet on alternate days in the same physical location; each clinic uses its own mailing address and telephone number. |
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| classCode [1..1] (M) Role (CS) {CNE:V:RoleClassServiceDeliveryLocation, root= "SDLOC"} |
Design Comments: Structural attribute; this is a "service delivery location" role |
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| id [0..*] Role (DSET<II>) |
Design Comments: Identifier(s) for this service delivery location |
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| code [0..1] Role (CD) {CWE:V:ServiceDeliveryLocationRoleType} |
Design Comments: A value further specifying what type of service delivery location this is, drawn from the ServiceDeliveryLocationRoleType domain. A service delivery location may be either an incidental service delivery location (a place at which services may be provided without prior designation or authorization) or a dedicated service delivery location (a place that is intended to house the provision of services). Dedicated service delivery locations can be further characterized as either clinical (DedicatedClinicalLocationRoleType) or non-clinical (DedicatedNonClinicalLocationRoleType). |
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| name [0..*] Role (COLL<EN>) |
Design Comments: A textual name for this service delivery location |
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| addr [0..*] Role (COLL<AD>) |
Design Comments: Address(es) for a place playing this service delivery location role |
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| telecom [0..*] Role (COLL<TEL>) |
Design Comments: Telecommunication address(es) for a place playing this service delivery location role |
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| statusCode [0..1] Role (CS) {CNE:V:RoleStatus} |
Design Comments: A value specifying the state of this service delivery location (based on the RIM Role class state-machine), for example, pending, active, suspended, terminated. |
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| effectiveTime [0..1] Role (IVL<TS>) |
Design Comments: An interval of time specifying the period during which this service delivery location role is in effect, if such time limit is applicable and known |
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| location [0..1] (E_PlaceUniversal) | |||||||||
| serviceProviderOrganization [0..1] (E_OrganizationIdentified) | |||||||||
| InFulfillmentOf |
Design Comments: An association of a patient encounter to the appointment that scheduled it |
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| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:ActRelationshipFulfills, root= "FLFS"} |
Design Comments: Structural attribute; this is a "fulfills" participation |
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| contextControlCode [1..1] (M) ActRelationship (CS) {CNE:V:ContextControl, default= "AN"} |
Design Comments: A value describing how A_Appointment (descendant act) contributes to the conductible context of the focal encounter (ancestor act). The default is that it does not overwrite or propagate. |
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| contextConductionInd [1..1] (M) ActRelationship (BL){default= "true"} |
Design Comments: Indicates whether A_Appointment (descendant act) inherits context (i.e., subject participation) from the focal encounter (ancestor act). The default is "true"; the encounter and appointment have the same patient. |
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| appointment [1..1] (A_AppointmentUniversal) | |||||||||
| SequelTo |
Design Comments: Association to a previous encounter for the same patient. Examples include: (1) a patient in an inpatient encounter is admitted as an inpatient after an evaluation of the seriousness of the patient's condition, (2) an inpatient is discharged from an inpatient encounter directly to an inpatient encounter as part of the same episode of care, (3) a patient is re-admitted to a healthcare facility. |
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| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:ActRelationshipSequel, root= "SEQL"} |
Design Comments: Structural attribute; this is an "is sequel" act relationship |
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| contextControlCode [1..1] (M) ActRelationship (CS) {CNE:V:ContextControl, default= "AN"} |
Design Comments: A value describing how the sequelTo A_Encounter (descendant act) contributes to the conductible context of the focal encounter (ancestor act). The default is that it does not overwrite or propagate. |
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| contextConductionInd [1..1] (M) ActRelationship (BL){default= "true"} |
Design Comments: Indicates whether the sequelTo A_Encounter (descendant act) inherits context (i.e., subject participation) from the focal encounter (ancestor act). The default is "true"; both encounters have the same patient. |
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| encounter [1..1] (A_EncounterUniversal) | |||||||||
| Reason1 |
Design Comments: Association to a diagnosis observation. Each diagnosis is sent in a separate A_ObservationDx CMET. The type of diagnosis is determined by the Observation.code within the A_ObservationDx CMET; "ADMX" for an admission diagnosis, "INTDX" for an interim diagnosis, and "DISDX" for a discharge diagnosis. |
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| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:ActRelationshipReason, root= "RSON"} |
Design Comments: Structural attribute, this is a "reason" act relationship |
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| contextControlCode [1..1] (M) ActRelationship (CS) {CNE:V:ContextControl, default= "AN"} |
Design Comments: A value describing how A_ObservationDX (descendant act) contributes to the conductible context of the focal encounter (ancestor act). The default is that it does not overwrite or propagate. |
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| contextConductionInd [1..1] (M) ActRelationship (BL){default= "true"} |
Design Comments: Indicates whether A_ObservationDx (descendant act) inherits context (i.e., subject participation) from the focal encounter (ancestor act). The default is "true"; the patient is the subject of the observation. |
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| priorityNumber [0..1] ActRelationship (INT) |
Design Comments: An integer specifying the relative preference for considering diagnoses of the same type (admitting, interim, or discharge). Diagnoses with lower priorityNumber values are considered before and above those with higher values. |
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| observationDx [1..1] (A_ObservationDxMinimal) | |||||||||
| Authorization |
Design Comments: Association to a consent granted by the patient or patient's representative authorizing the focal encounter. Each consent is sent in a separate A_Consent CMET. Note, this is currently a placeholder CMET until the Medical Records TC completes work on medico-legal document modeling. |
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| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:ActRelationshipAuthorizedBy, root= "AUTH"} |
Design Comments: Structural attribute; this is a "authorized by" act relationship |
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| contextControlCode [1..1] (M) ActRelationship (CS) {CNE:V:ContextControl, default= "AN"} |
Design Comments: A value describing how A_Consent (descendant act) contributes to the conductible context of the focal encounter (ancestor act). The default is that it does not overwrite or propagate. |
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| contextConductionInd [1..1] (M) ActRelationship (BL){default= "false"} |
Design Comments: Indicates whether A_Consent (descendant act) inherits context (i.e., subject participation) from the focal encounter (ancestor act). The default is "false". Consent does not have a subject participation, instead the patient is the author of the consent. |
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| consent [1..1] (A_ConsentUniversal) | |||||||||
| Reference |
Design Comments: An optional association to one or more patient accounts. Each account with its associated account holder (guarantor) is sent in a separate A_AccountGuarantor CMET. |
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| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:ActRelationshipRefersTo, root= "REFR"} |
Design Comments: Structural attribute; this is a "refers to" act relationship |
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| contextControlCode [1..1] (M) ActRelationship (CS) {CNE:V:ContextControl, default= "AN"} |
Design Comments: A value describing how A_AccountGuarantor (descendant act) contributes to the conductible context of the focal encounter (ancestor act). The default is that it does not overwrite or propagate. |
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| contextConductionInd [1..1] (M) ActRelationship (BL){default= "false"} |
Design Comments: Indicates whether A_AccountGuarntor (descendant act) inherits context (i.e., subject participation) from the focal encounter (ancestor act).. The default is "false". The account does not have a subject participation; the patient is the scoper of the GuarantorRole. |
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| account [1..1] (A_AccountGuarantorUniversal) | |||||||||
| ItemStorage |
Design Comments: Association to a report of patient valuables stored during the patient encounter. The report is sent as a free text observation of the valuables and where they are stored during the encounter. |
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| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:ActRelationshipItemsLocated, root= "ITEMSLOC"} |
Design Comments: Structural attribute; this is a "items located" act relationship |
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| contextControlCode [1..1] (M) ActRelationship (CS) {CNE:V:ContextControl, default= "AN"} |
Design Comments: A value describing how the items storage act (descendant act) contributes to the conductible context of the focal encounter (ancestor act). The default is that the context does not overwrite or propagate. |
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| contextConductionInd [1..1] (M) ActRelationship (BL){default= "false"} |
Design Comments: Indicates whether the Valuables Location observation (descendant act) inherits context (i.e., subject participation) from the focal encounter (ancestor act). The default is "false"; the patient is not the subject of the observation. |
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| valuablesLocation [1..1] (ValuablesLocation) |
Design Comments: An observation reporting on a patient's valuables stored for safekeeping during a patient encounter |
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| ValuablesLocation |
Design Comments: An observation reporting on a patient's valuables stored for safekeeping during a patient encounter |
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| classCode [1..1] (M) Observation (CS) {CNE:V:ActClassObservation, root= "OBS"} |
Design Comments: This is an "observation" act |
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| moodCode [1..1] (M) Observation (CS) {CNE:V:ActMoodEventOccurrence, root= "EVN"} |
Design Comments: This is an observation event |
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| value [1..1] Observation (ED) |
Design Comments: Description of patient valuables and where they were stored for safekeeping during the encounter |
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| ArrivedBy |
Design Comments: Association of a patient encounter to information about the patient's arrival at the site of the patient encounter |
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| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:ActRelationshipArrival, root= "ARR"} |
Design Comments: Structural attribute; this is an "arrival" act relationship |
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| contextControlCode [1..1] (M) ActRelationship (CS) {CNE:V:ContextControl, default= "AN"} |
Design Comments: A value describing how the patient arrival transportation act (descendant act) contributes to the conductible context of the focal encounter (ancestor act). The default is that it does not overwrite or propagate. |
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| contextConductionInd [1..1] (M) ActRelationship (BL){default= "true"} |
Design Comments: Indicates whether the patient arrival transportation act (descendant act) inherits context (i.e., subject participation) from the focal encounter (ancestor act). The default is "true"; the transportation and the encounter have the same subject. |
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| transportationEvent [1..1] (TransportationEvent) |
Design Comments: Transportation of the patient to the encounter site |
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| TransportationEvent |
Design Comments: Transportation of the patient to the encounter site |
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| classCode [1..1] (M) Act (CS) {CNE:V:ActClassTransportation, root= "TRNS"} |
Design Comments: Structural attribute; this is a "transportation" act |
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| moodCode [1..1] (M) Act (CS) {CNE:V:ActMoodEventOccurrence, root= "EVN"} |
Design Comments: Structural attribute; this a transportation event |
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| id [0..*] Act (DSET<II>) |
Design Comments: Identifier(s) for this transportation act |
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| code [1..1] Act (CD) {CWE:D:ActPatientTransportationModeCode} |
Design Comments: A value specifying the mode of transportation. Examples include ambulance, private transport, public transport, on foot. |
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| text [0..1] Act (ED) |
Design Comments: A textual description of this transportation act |
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| effectiveTime [0..1] Act (IVL<TS>) |
Design Comments: The time the patient is en route. The end of the time interval represents when the patient arrived at the encounter site. |
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| priorityCode [0..1] Act (CD) {CWE:D:ActPriority} |
Design Comments: A value (e.g., for routine, emergency), specifying the urgency under which the transportation act happened |
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| confidentialityCode [0..*] Act (DSET<CD>) {CWE:D:Confidentiality} |
Design Comments: Value(s) that control the disclosure of information about this transportation act |
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| performer [0..*] (Performer2) |
Design Comments: Association to a person who transported the patient to the encounter site |
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| escort [0..*] (Escort1) |
Design Comments: Association to a person who escorted the patient to the encounter site |
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| location [0..*] (Location4) |
Design Comments: Association to the patient's starting location and any locations transited during the transportation act |
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| Performer2 |
Design Comments: Association to a person who transported the patient to the encounter site |
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| typeCode [1..1] (M) Participation (CS) {CNE:V:ParticipationPhysicalPerformer, root= "PRF"} |
Design Comments: Structural attribute; this is a "performer" participation |
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| time [0..1] Participation (IVL<TS>) |
Design Comments: An interval of time specifying the period this person transported the patient. Note, this would be used only if the person did not participate for the full duration of the transport. |
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| assignedPerson [1..1] (AssignedPerson) | |||||||||
| Escort1 |
Design Comments: Association to a person who escorted the patient to the encounter site |
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| typeCode [1..1] (M) Participation (CS) {CNE:V:ParticipationEscort, root= "ESC"} |
Design Comments: Structural attribute; this is an "escort" participation |
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| time [0..1] Participation (IVL<TS>) |
Design Comments: An interval of time specifying the period this person escorted the patient. Note, this is only needed if the escort did not participate for the full duration of the patient transport. |
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| assignedPerson [1..1] (AssignedPerson) |
Design Comments: A person assigned to participate in a patient transportation as performer or escort |
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| AssignedPerson |
Design Comments: A person assigned to participate in a patient transportation as performer or escort |
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| classCode [1..1] (M) Role (CS) {CNE:V:RoleClassAssignedEntity, root= "ASSIGNED"} |
Design Comments: Structural attribute; this is an "assigned" role |
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| id [0..1] Role (II) |
Design Comments: An identifer for a person assigned to participate in a patient transportation as performer or escort |
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| telecom [0..1] Role (TEL) |
Design Comments: A telecommunication address for a person assigned to participate in a patient transportation as performer or escort |
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| assignedPerson [0..1] (Person) |
Design Comments: A subtype of LivingSubject representing a human being |
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| representedOrganization [0..1] (Organization) |
Design Comments: A social or legal structure formed by human beings |
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| Person |
Design Comments: A subtype of LivingSubject representing a human being |
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| classCode [1..1] (M) Person (CS) {CNE:V:EntityClassPerson, root= "PSN"} |
Design Comments: Structural attribute; this is a 'person' type of entity |
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| determinerCode [1..1] (M) Person (CS) {CNE:V:EntityDeterminerSpecific, root= "INSTANCE"} |
Design Comments: Structural attribute; this is a specific entity |
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| name [0..1] Person (PN) |
Design Comments: A non-unique textual identifier or moniker for a person |
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| Organization |
Design Comments: A social or legal structure formed by human beings |
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| classCode [1..1] (M) Organization (CS) {CNE:V:EntityClassOrganization, root= "ORG"} |
Design Comments: Structural attribute; this is an 'organization' type of entity |
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| determinerCode [1..1] (M) Organization (CS) {CNE:V:EntityDeterminerSpecific, root= "INSTANCE"} |
Design Comments: Structural attribute; this is a specific entity |
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| name [0..1] Organization (ON) |
Design Comments: A non-unique textual identifier or moniker for an organization |
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| telecom [0..1] Organization (TEL) |
Design Comments: A telecommunication address for an organization |
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| addr [0..1] Organization (AD) |
Design Comments: The postal and/or residential address of an organization |
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| Location4 |
Design Comments: Association to the patient's starting location and any locations transited during the transportation act |
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| typeCode [1..1] (M) Participation (CS) {CNE:V:ParticipationTargetLocation, root= "LOC"} |
Design Comments: Structural attribute; this is a "location" participation. Allowed specializations include origin and via. A location type of "destination" would not be used in a patient arrival because the encounter site is the destination location. |
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| sequenceNumber [0..1] Participation (INT.NONNEG) |
Design Comments: An integer specifying the relative order of locations transited in a multi-segment transportation act |
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| locatedEntity [1..1] (R_LocationLocatedEntityContact) | |||||||||
| DepartedBy |
Design Comments: Association of a patient encounter to information about the patient's departure from the site of the patient encounter |
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| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:ActRelationshipDeparture, root= "DEP"} |
Design Comments: Structural attribute; this is an "departure" act relationship |
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| contextControlCode [1..1] (M) ActRelationship (CS) {CNE:V:ContextControl, default= "AN"} |
Design Comments: A value describing how the patient departure transportation act (descendant act) contributes to the conductible context of the focal encounter (ancestor act). The default is that it does not overwrite or propagate. |
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| contextConductionInd [1..1] (M) ActRelationship (BL){default= "true"} |
Design Comments: Indicates whether the patient departure transportation act (descendant act) inherits context (i.e., subject participation) from the focal encounter (ancestor act). The default is "true"; the transportation and encounter have the same subject. |
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| transportationIntent [1..1] (TransportationIntent) |
Design Comments: An intention or plan to transport the patient from the encounter site |
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| TransportationIntent |
Design Comments: An intention or plan to transport the patient from the encounter site |
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| classCode [1..1] (M) Act (CS) {CNE:V:ActClassTransportation, root= "TRNS"} |
Design Comments: Structural attribute; this is a "transportation" act |
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| moodCode [1..1] (M) Act (CS) {CNE:V:ActMoodIntent, root= "INT"} |
Design Comments: Structural attribute; this a transportation intent |
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| id [0..*] Act (DSET<II>) |
Design Comments: Identifier(s) for this transportation act |
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| code [1..1] Act (CD) {CWE:D:ActPatientTransportationModeCode} |
Design Comments: A value specifying the mode of transportation. Examples include ambulance, private transport, public transport, on foot. |
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| text [0..1] Act (ED) |
Design Comments: A textual description of this transportation act |
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| effectiveTime [0..1] Act (IVL<TS>) |
Design Comments: The planned time for the patient to be en route. The start of the time interval represents when the patient is expected to depart from the encounter site. |
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| priorityCode [0..1] Act (CD) {CWE:D:ActPriority} |
Design Comments: A value (e.g., for routine, emergency), specifying the urgency for the intended transportation act |
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| confidentialityCode [0..*] Act (DSET<CD>) {CWE:D:Confidentiality} |
Design Comments: Value(s) that control the disclosure of information about this transportation act |
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| performer [0..*] (Performer1) |
Design Comments: Association to a person who is intended to transport the patient from the encounter site |
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| escort [0..*] (Escort2) |
Design Comments: Association to a person who is intended to escort the patient from the encounter site |
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| location [0..*] (Location3) |
Design Comments: Association to the patient's destination location and any locations intended to be transited during the transportation act |
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| Performer1 |
Design Comments: Association to a person who is intended to transport the patient from the encounter site |
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| typeCode [1..1] (M) Participation (CS) {CNE:V:ParticipationPhysicalPerformer, root= "PRF"} |
Design Comments: Structural attribute; this is a "performer" participation |
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| time [0..1] Participation (IVL<TS>) |
Design Comments: An interval of time specifying the period this person is intended to transport the patient. Note, this would be used only if the person is not intended to participate for the full duration of the transport. |
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| assignedPerson [1..1] (AssignedPerson) | |||||||||
| Escort2 |
Design Comments: Association to a person who is intended to escort the patient from the encounter site |
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| typeCode [1..1] (M) Participation (CS) {CNE:V:ParticipationEscort, root= "ESC"} |
Design Comments: Structural attribute; this is an "escort" participation |
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| time [0..1] Participation (IVL<TS>) |
Design Comments: An interval of time specifying the period this person is intended to escort the patient. Note, this would be used only if the person is not intended to participate for the full duration of the transport. |
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| assignedPerson [1..1] (AssignedPerson) | |||||||||
| Location3 |
Design Comments: Association to the patient's destination location and any locations intended to be transited during the transportation act |
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| typeCode [1..1] (M) Participation (CS) {CNE:V:ParticipationTargetLocation, root= "LOC"} |
Design Comments: Structural attribute; this is a "location" participation. Allowed specializations include destination and via. A location type of "origin" would not be used in a patient departure because the encounter site is the origin location |
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| sequenceNumber [0..1] Participation (INT.NONNEG) |
Design Comments: An integer specifying the relative order of locations to be transited in a multi-segment transportation act |
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| locatedEntity [1..1] (R_LocationLocatedEntityContact) | |||||||||
| Reason2 |
Design Comments: An optional association linking a pre-admission patient encounter (source) for tests or other preparation to the focal encounter (target) that is required the pre-admission encounter. Note that the focal encounter should have the preAdmitTestInd attribute set to "true". Both encounters will have the same subject (patient). |
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| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:ActRelationshipReason, root= "RSON"} |
Design Comments: Structural attribute; this is a "has reason" act relationship |
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| contextControlCode [1..1] (M) ActRelationship (CS) {CNE:V:ContextControl, default= "AN"} |
Design Comments: A value describing how a pre-admission encounter (descendant act) contributes to the conductible context of the focal encounter (ancestor act). The default is that it does not overwrite or propagate. |
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| contextConductionInd [1..1] (M) ActRelationship (BL){default= "true"} |
Design Comments: Indicates whether a pre-admission encounter (descendant act) inherits context (i.e., subject participation) from the focal encounter (ancestor act). The default is "true"; both encounters have the same patient. |
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| encounter [1..1] (A_EncounterUniversal) | |||||||||
| Component |
Design Comments: An optional association from the focal encounter (target) to an overall care event (source) of which it is a component. The care event represents someone (generally a health care practitioner) taking responsibility for some aspect of a patient's health; examples include primary/preferred care provider, case manager. UsageNotes: Associates an encounter with an overall Care Event |
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| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:ActRelationshipHasComponent, root= "COMP"} |
Design Comments: Structural attribute; this is a "has component" act relationship |
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| contextControlCode [1..1] (M) ActRelationship (CS) {CNE:V:ContextControl, default= "AN"} |
Design Comments: A value describing how the containing care event (descendant act) contributes to the conductible context of the focal encounter (ancestor act). The default is that it does not overwrite or propagate. |
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| contextConductionInd [1..1] (M) ActRelationship (BL){default= "true"} |
Design Comments: Indicates whether the containing care event (descendant act) inherits context (i.e., subject participation) from the focal encounter (ancestor act). The default is "true". |
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| patientCareProvisionEvent [1..1] (A_CareEventIdentified) | |||||||||