| PRPA_HD414001UV02 Active Home Health Encounter Appointment |
(Link to Excel View) Derived from RMIM: PRPA_RM414001UV02 |
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| HomeHealthEncounterAppointment |
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 appointment 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:ActMoodAppointment, root= "APT"} |
Design Comments: Structural attribute; this is a patient encounter appointment |
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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: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 planned 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). |
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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 quantity of time for the patient encounter. |
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| preAdmitTestInd [0..1] PatientEncounter (BL) |
Design Comments: Indicates whether tests were done in a preadmission encounter prior to this appointment. 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..1] (Location1) |
Design Comments: An association to a patient's assigned location during a patient encounter. |
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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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| 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) Participation (CS) {CNE:V:ParticipationResponsibleParty, root= "RESP"} |
Design Comments: Structural attribute; this is a "responsibility" participation |
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| contextControlCode [1..1] (M) Participation (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] Participation (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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| 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) Participation (CS) {CNE:V:ParticipationAttender, root= "ATND"} |
Design Comments: Structural attribute; this is an "attender" participation |
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| contextControlCode [1..1] (M) Participation (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] Participation (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] Participation (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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| 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) Participation (CS) {CNE:V:ParticipationTargetLocation, root= "LOC"} |
Design Comments: Structural attribute; this is a "location" participation |
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| contextControlCode [1..1] (M) Participation (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] Participation (IVL<TS>) |
Design Comments: An interval of time specifying the period the patient is assigned to this location |
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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) | |||||||||
| 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) | |||||||||
| 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) | |||||||||