| PRPA_HD404003UV02 Completed Home Health Encounter |
(Link to Excel View) Derived from RMIM: PRPA_RM404003UV02 |
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| HomeHealthEncounterEvent |
Design Comments: An interaction between a patient and care provider(s) for the purpose of providing healthcare-related service(s). This is a home health encounter characterized by services being provided or supervised by a practitioner at the patient's residence. Services may include recurring visits for chronic or terminal conditions or visit(s) facilitating recuperation. |
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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:ActEncounterHomeHealthType} |
Design Comments: A value further specifying the type of patient encounter. This is constrained to "home health". |
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| statusCode [1..1] (M) PatientEncounter (CS) {CNE:V:ActStatusCompleted} |
Design Comments: A value specifying the state of this patient encounter; this is 'completed'. |
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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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| 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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| 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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| discharger [0..1] (Discharger) |
Design Comments: Association to the practitioner who required or authorized the ending of this patient encounter. |
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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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| 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) | |||||||||
| Discharger |
Design Comments: Association to the practitioner who required or authorized the ending of this patient encounter. |
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| typeCode [1..1] (M) Participation (CS) {CNE:V:ParticipationDischarger, root= "DIS"} |
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| contextControlCode [1..1] (M) Participation (CS) {CNE:V:ContextControl, default= "AN"} |
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| time [0..1] Participation (IVL<TS>) |
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| modeCode [0..1] Participation (CD) {CWE:D:ParticipationMode} |
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| assignedPerson [1..1] (R_AssignedPersonUniversal) | |||||||||
| 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) | |||||||||