| PRPA_MT402003UV02 Completed Inpatient Encounter |
Derived from RMIM: PRPA_RM402003UV02 and HMD: PRPA_HD402003UV02 |
||||||||
| InpatientEncounterEvent |
Design Comments: An interaction between a patient and care provider(s) for the purpose of providing healthcare-related service(s). This is an inpatient encounter; the patient is admitted by a hospital or equivalent facility, assigned to a location where patients generally stay at least overnight and provided with room, board, and continuous nursing service. |
||||||||
| classCode [1..1] (M) PatientEncounter (CS) {CNE:V:ActClassEncounter, root= "ENC"} |
Design Comments: Structural attribute; this is a "patient encounter" act |
||||||||
| moodCode [1..1] (M) PatientEncounter (CS) {CNE:V:ActMoodEventOccurrence, root= "EVN"} |
Design Comments: Structural attribute; this is a patient encounter event |
||||||||
| 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) |
||||||||
| code [1..1] (M) PatientEncounter (CD) {CWE:D:ActEncounterInpatientType} |
Design Comments: A value further specifying the type of patient encounter. This is constrained to "inpatient". |
||||||||
| statusCode [1..1] (M) PatientEncounter (CS) {CNE:V:ActStatusCompleted} |
Design Comments: A value specifying the state of this patient encounter; this is 'completed'. |
||||||||
| 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. |
||||||||
| 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 |
||||||||
| 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. |
||||||||
| 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. |
||||||||
| 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. |
||||||||
| discharger [0..1] (Discharger) |
Design Comments: Association to the practitioner who required or authorized the ending of this patient encounter. |
||||||||
| 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. |
||||||||
| 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 |
||||||||
| 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. |
||||||||
| typeCode [1..1] (M) Participation (CS) {CNE:V:ParticipationTargetSubject, root= "SBJ"} |
Design Comments: Structural attribute; this is a "ParticipationTargetSubject" participation |
||||||||
| 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. |
||||||||
| patient [1..1] (R_PatientIdentified-confirmable) | |||||||||
| Discharger |
Design Comments: Association to the practitioner who required or authorized the ending of this patient encounter. |
||||||||
| typeCode [1..1] (M) Participation (CS) {CNE:V:ParticipationDischarger, root= "DIS"} |
|||||||||
| contextControlCode [0..1] Participation (CS) {CNE:V:ContextControl} |
Design Comments: A value describing how the discharger 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 discharger and does not propagate to any acts associated with the focal encounter. |
||||||||
| time [0..1] Participation (IVL<TS>) |
Design Comments: An interval of time specifying the period this practitioner was actively involved in ending this patient encounter. |
||||||||
| modeCode [0..1] Participation (CD) {CWE:D:ParticipationMode} |
Design Comments: A code specifying the modality by which the practitioner authorized the end of this patient encounter. Examples include, physically present, over the telephone, written communication. |
||||||||
| 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. |
||||||||
| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:ActRelationshipReason, root= "RSON"} |
Design Comments: Structural attribute, this is a "reason" act relationship |
||||||||
| 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. |
||||||||
| 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. |
||||||||
| 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. |
||||||||
| observationDx [1..1] (A_ObservationDxMinimal) | |||||||||
| DepartedBy |
Design Comments: Association of a patient encounter to information about the patient's departure from the site of the patient encounter |
||||||||
| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:ActRelationshipDeparture, root= "DEP"} |
Design Comments: Structural attribute; this is an "departure" act relationship |
||||||||
| 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. |
||||||||
| 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. |
||||||||
| transportationEvent [1..1] (TransportationEvent) |
Design Comments: Transportation of the patient from the encounter site. |
||||||||
| TransportationEvent |
Design Comments: Transportation of the patient from the encounter site. |
||||||||
| classCode [1..1] (M) Act (CS) {CNE:V:ActClassTransportation, root= "TRNS"} |
Design Comments: Structural attribute; this is a "transportation" act |
||||||||
| moodCode [1..1] (M) Act (CS) {CNE:V:ActMoodEventOccurrence, root= "EVN"} |
Design Comments: Structural attribute; this a transportation event |
||||||||
| id [0..*] Act (DSET<II>) |
Design Comments: Identifier(s) for this transportation act |
||||||||
| 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. |
||||||||
| text [0..1] Act (ED) |
Design Comments: A textual description of this transportation act |
||||||||
| effectiveTime [0..1] Act (IVL<TS>) |
Design Comments: The time the patient is en route. The start of the time interval represents when the patient departed from the encounter site. |
||||||||
| priorityCode [0..1] Act (CD) {CWE:D:ActPriority} |
Design Comments: A value (e.g., for routine, emergency), specifying the urgency of the transportation act |
||||||||
| confidentialityCode [0..*] Act (DSET<CD>) {CWE:D:Confidentiality} |
Design Comments: Value(s) that control the disclosure of information about this transportation act |
||||||||
| performer [0..*] (Performer1) |
Design Comments: Association to a person who transported the patient from the encounter site |
||||||||
| escort [0..*] (Escort2) |
Design Comments: Association to a person who escorted the patient from the encounter site |
||||||||
| location [0..*] (Location3) |
Design Comments: Association to the patient's destination location and any locations intended to be transited during the transportation act |
||||||||
| Performer1 |
Design Comments: Association to a person who transported the patient from the encounter site |
||||||||
| typeCode [1..1] (M) Participation (CS) {CNE:V:ParticipationPhysicalPerformer, root= "PRF"} |
Design Comments: Structural attribute; this is a "performer" participation |
||||||||
| 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. |
||||||||
| assignedPerson [1..1] (AssignedPerson) | |||||||||
| Escort2 |
Design Comments: Association to a person who escorted the patient from the encounter site |
||||||||
| typeCode [1..1] (M) Participation (CS) {CNE:V:ParticipationEscort, root= "ESC"} |
Design Comments: Structural attribute; this is an "escort" participation |
||||||||
| time [0..1] Participation (IVL<TS>) |
Design Comments: An interval of time specifying the period this person escorted the patient. Note, this would be used only if the person did not participate for the full duration of the transport. |
||||||||
| assignedPerson [1..1] (AssignedPerson) |
Design Comments: A person assigned to participate in a patient transportation as performer or escort |
||||||||
| AssignedPerson |
Design Comments: A person assigned to participate in a patient transportation as performer or escort |
||||||||
| classCode [1..1] (M) Role (CS) {CNE:V:RoleClassAssignedEntity, root= "ASSIGNED"} |
Design Comments: Structural attribute; this is an "assigned" role |
||||||||
| id [0..1] Role (II) |
Design Comments: An identifer for a person assigned to participate in a patient transportation as performer or escort |
||||||||
| telecom [0..1] Role (TEL) |
Design Comments: A telecommunication address for a person assigned to participate in a patient transportation as performer or escort |
||||||||
| assignedPerson [0..1] (Person) |
Design Comments: A subtype of LivingSubject representing a human being |
||||||||
| representedOrganization [0..1] (Organization) |
Design Comments: A social or legal structure formed by human beings |
||||||||
| Person |
Design Comments: A subtype of LivingSubject representing a human being |
||||||||
| classCode [1..1] (M) Person (CS) {CNE:V:EntityClassPerson, root= "PSN"} |
Design Comments: Structural attribute; this is a 'person' type of entity |
||||||||
| determinerCode [1..1] (M) Person (CS) {CNE:V:EntityDeterminerSpecific, root= "INSTANCE"} |
Design Comments: Structural attribute; this is a specific entity |
||||||||
| name [0..1] Person (PN) |
Design Comments: A non-unique textual identifier or moniker for a person |
||||||||
| Organization |
Design Comments: A social or legal structure formed by human beings |
||||||||
| classCode [1..1] (M) Organization (CS) {CNE:V:EntityClassOrganization, root= "ORG"} |
Design Comments: Structural attribute; this is an 'organization' type of entity |
||||||||
| determinerCode [1..1] (M) Organization (CS) {CNE:V:EntityDeterminerSpecific, root= "INSTANCE"} |
Design Comments: Structural attribute; this is a specific entity |
||||||||
| name [0..1] Organization (ON) |
Design Comments: A non-unique textual identifier or moniker for an organization |
||||||||
| telecom [0..1] Organization (TEL) |
Design Comments: A telecommunication address for an organization |
||||||||
| addr [0..1] Organization (AD) |
Design Comments: The postal and/or residential address of an organization |
||||||||
| Location3 |
Design Comments: Association to the patient's destination location and any locations intended to be transited during the transportation act |
||||||||
| 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 |
||||||||
| 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 |
||||||||
| locatedEntity [1..1] (R_LocationLocatedEntityContact) | |||||||||