Definition:

Acknowledgement Condition codes describe the conditions under which accept or application level acknowledgements are required to be returned in response to the message send operation.

Definition:

A site specific code indicating the specific problem being reported by this Ack Detail.

Definition:

Refelects rejections because elements of the communication are not supported in the current context.

Definition:

Reflects errors in the syntax or structure of the communication.

Definition:

A code identifying the specific message to be provided.

A textual value may be specified as the print name, or for non-coded messages, as the original text. Discussion:

'Required attribute xxx is missing', 'System will be unavailable March 19 from 0100 to 0300' Examples:

Definition:

Identifies the the kind of information specified in the acknowledgement message. Options are: Error, Warning or Information.

Definition:

Acknowledgement code as described in HL7 message processing rules.

Definition:

Description: Types of acts that can be scheduled.

Examples:

• Follow-up appointment
• New referral appointment
• Consultation appointment
• Specimen Collection appointment
• Procedure appointment

Definition:

A code specifying the major type of Act that this Act-instance represents.

Constraints: The classCode domain is a tightly controlled vocabulary, not an external or user-defined vocabulary.

Every Act-instance must have a classCode. If the act class is not further specified, the most general Act.classCode (ACT) is used.

The Act.classCode must be a generalization of the specific Act concept (e.g., as expressed in Act.code), in other words, the Act concepts conveyed in an Act must be specializations of the Act.classCode. Especially, Act.code is not a "modifier" that can alter the meaning of a class code. (See Act.code for contrast.)

Definition:

Description:The interaction of entities whereupon a subject entity is brought into proximity to a physical, chemical or biological agent. This includes intended exposure (e.g. administering a drug product) as well as accidental or environmental exposure. (Note: This class deals only with proximity and not the effectiveness of the exposure, i.e. not all exposed will suffer actual harm or benefit.)

Examples:Exposure to radiation, drug administration, inhalation of peanut aerosol or viral particles.

Definition:

Description:An observation of genomic phenomena.

Definition:

Description:A mandate, regulation, obligation, requirement, rule, or expectation unilaterally imposed by one party on:

• The activity of another party

• The behavior of another party

• The manner in which an act is executed

Definition:

An Act whose immediate and primary outcome (post-condition) is the alteration of the physical condition of the subject.

Examples: : Procedures may involve the disruption of some body surface (e.g. an incision in a surgical procedure), but they also include conservative procedures such as reduction of a luxated join, chiropractic treatment, massage, balneotherapy, acupuncture, shiatsu, etc. Outside of clinical medicine, procedures may be such things as alteration of environments (e.g. straightening rivers, draining swamps, building dams) or the repair or change of machinery etc.

Definition:

The act of putting something away for safe keeping. The "something" may be physical object such as a specimen, or information, such as observations regarding a specimen.

Definition:

The spatial relationship of a subject whether human, other animal, or plant, to a frame of reference such as gravity or a collection device.

Definition:

A code specifying qualitatively the spatial relation between imaged object and imaging film or detector.

Definition:

Contains codes for defining the observed, physical position of a subject, such as during an observation, assessment, collection of a specimen, etc. ECG waveforms and vital signs, such as blood pressure, are two examples where a general, observed position typically needs to be noted.

Definition:

The table that provides the detailed or rich codes for the Act classes.

Definition:

Description: Types of representation groupings of financial transactions that are tracked and reported together with a single balance.

Examples:

• Patient billing accounts

• Cost center

• Cash

Property:   ConceptualSpaceForClassCode: ActClass.ACCT

Definition:

Description: Types of responses that will occur as a result of the adjudication of an electronic invoice at a summary level and provides guidance on interpretation of the referenced adjudication results.

Examples:

• adjudicated with adjustments

• adjudicated as refused

• adjudicated as submitted

Property:   ConceptualSpaceForClassCode: ActClass.ADJUD

Definition:

Explanatory codes that provide information derived by an Adjudicator during the course of adjudicating an Invoice. Codes from this domain are purely information and do not materially affect the adjudicated Invoice. That is, codes do not impact or explain financial adjustments to an Invoice.

A companion domain (ActAdjudicationReason) includes information reasons which have a financial impact on an Invoice (claim).

Example adjudication information code is 54540 - Patient has reached Plan Maximum for current year.

Codes from this domain further rationalizes ActAdjudicationCodes (e.g. AA - Adjudicated with Adjustment), which are used to describe the process of adjudicating an Invoice.

Property:   ConceptualSpaceForClassCode: ActClass.ADJUD

Definition:

Description: Actions to be carried out by the recipient of the Adjudication Result information.

Definition:

Description:The type and scope of responsibility taken-on by the performer of the Act for a specific subject of care.

Property:   ConceptualSpaceForClassCode: ActClass.PCPR

Definition:

Description:Concepts identifying different types of referral requests. These concepts identify the general type of care or category of services requested. They are not used to represent the indication or diagnosis which triggered the need for the referral. E.g. Anger management service, Intensive Care service, Orthodontics service.

Definition:

Description:The type and scope of legal and/or professional responsibility taken-on by the performer of the Act for a specific subject of care as described by a credentialing agency, i.e. government or non-government agency. Failure in executing this Act may result in loss of credential to the person or organization who participates as performer of the Act. Excludes employment agreements.

Example:Hospital license; physician license; clinic accreditation.

Definition:

Description:The type and scope of legal and/or professional responsibility taken-on by the performer of the Act for a specific subject of care as described by an agency for credentialing individuals.

Definition:

Description:The type and scope of legal and/or professional responsibility taken-on by the performer of the Act for a specific subject of care as described by an agency for credentialing programs within organizations.

Definition:

Definition:Concepts representing types of patient encounter such as ambulatory encounter, inpatient encounter or emergency encounter.

Definition:

Definition:A comprehensive term for health care provided in a healthcare facility (e.g. a practitioneraTMs office, clinic setting, or hospital) on a nonresident basis. The term ambulatory usually implies that the patient has come to the location and is not assigned to a bed. Sometimes referred to as an outpatient encounter.

Definition:

Definition:A patient encounter that takes place at a dedicated healthcare service delivery location where the patient receives immediate evaluation and treatment, provided until the patient can be discharged or responsibility for the patient's care is transferred elsewhere (for example, the patient could be admitted as an inpatient or transferred to another facility.)

Definition:

Definition:A patient encounter that takes place both outside a dedicated service delivery location and outside a patient's residence. Example locations might include an accident site and at a supermarket.

Definition:

Definition:Healthcare encounter that takes place in the residence of the patient or a designee

Definition:

Definition:A patient encounter where a 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.

Definition:

Definition:An encounter where the patient is admitted to a health care facility for a predetermined length of time, usually less than 24 hours.

Definition:

Definition:A patient encounter where the patient and the practitioner(s) are not in the same physical location. Examples include telephone conference, email exchange, robotic surgery, and televideo conference.

Definition:

OpenIssue:

Property:   ConceptualSpaceForClassCode: ActClass.ENC

Definition:

Description: Codes for general process steps.

Examples:

• lab process steps

• diagnostic imaging process steps

• etc. (Missing third example)

Property:   ConceptualSpaceForClassCode: ActClass.SPCTRT

Definition:

Codes for general laboratory process steps.

Property:   ConceptualSpaceForClassCode: ActClass.ACT

Definition:

The act of storing information to long term storage.

Property:   ConceptualSpaceForClassCode: ActClass.STORE

Definition:

The act of verifying an observations. The subject act related to the observation verification (act relationship SUBJ) must be an observation (OBS)

Property:   ConceptualSpaceForClassCode: ActClass.OBS

Definition:

The accession act related to a specimen or group of specimens.

Property:   ConceptualSpaceForClassCode: ActClass.ACSN

Definition:

The act of printing a specimen label. The printing of a label for a specimen container is a significant act in the workflow for collecting specimens.

Property:   ConceptualSpaceForClassCode: ActClass.PROC

Definition:

The act of adding a specimen to a transportation manifest. For example a laboratory will pack together in a carton all the specimens to be shipped to a reference lab. An electronic manifest showing all the specimens in the shippment is communicated to the reference lab.

Property:   ConceptualSpaceForClassCode: ActClass.TRNS

Definition:

Transportation of a specimen.

Property:   ConceptualSpaceForClassCode: ActClass.TRNS

Definition:

Definition:Used to identify if a lab result is reported as preliminary, final, or corrected. Provides a consistent way to distinguish the business or reporting status of the lab result.

Definition:

Denotes the specific service that has been performed. This is obtained from the professional service catalog pertaining to the discipline of the health service provider. Professional services are generally cognitive in nature and exclude surgical procedures. E.g. Provided training, Provided drug therapy review, Gave smoking-cessation counseling, etc.

Property:   ConceptualSpaceForClassCode: ActClass.ACT

Definition:

Definition: The type of consent directive, e.g., to consent or dissent to collect, access, or use in specific ways within an EHRS or for health information exchange; or to disclose health information for purposes such as research.

Property:   ConceptualSpaceForClassCode: ActClass.CONS

Definition:

Description:The type of data consent directive.

Definition:

Description:The type of financial participation consent directive.

Examples: The Advanced Beneficiary Notice that Medicare patients consent or dissent to prior to receiving health services in the U.S. \ Current values include consent to financial responsibility (1) if the service is not deemed medically necessary; (2) will self pay for a service; or (3) requests that payer be billed.

Definition:

Description: The type of health information to which the subject of the information or the subject's delegate consents or dissents.

Examples:

• allergy information

• medication information

• professional services information

Definition:

Description:

Represents types of consent that patient must sign prior to receipt of service, which is required for billing purposes.

Examples:

• Advanced beneficiary medically necessity notice.

• Advanced beneficiary agreement to pay notice.

• Advanced beneficiary requests payer billed.

Property:   ConceptualSpaceForClassCode: ActClass.CONS

Definition:

An agreement of obligation between two or more parties that is subject to contractual law and enforcement.

Examples: approvals granted by a regulatory agency; contracts measured in financial terms; insurance coverage contracts.

Property:   ConceptualSpaceForClassCode: ActClass.CNTRCT

Definition:

A type of Act representing a contract whose value is measured in monetary terms.

Examples:

• insurance policy

• providercontract

• billing arrangement

Property:   ConceptualSpaceForClassCode: ActClass.FCNTRCT

Definition:

Definition: Set of codes indicating the type of insurance policy or program that pays for the cost of benefits provided to covered parties.

Property:   ConceptualSpaceForClassCode: ActClass.COV

Definition:

Indication of eligibility coverage for healthcare service(s) and/or product(s).

Property:   ConceptualSpaceForClassCode: ActClass.COV

Definition:

Criteria that are applicable to the authorized coverage.

Property:   ConceptualSpaceForClassCode: ActClass.COV

Definition:

Maximum amount paid or maximum number of services/products covered; or maximum amount or number covered during a specified time period under the policy or program.

Definition:

Codes representing the types of covered parties that may receive covered benefits under a policy or program.

OpenIssue: This concept domain should be reviewed to determine whether it needs a "ConceptualSpaceForClassCode" property to link to a RIM classCode.

Definition:

Codes representing the level of coverage provided under the policy or program in terms of the types of entities that may play covered parties based on their personal relationships or employment status.

OpenIssue: This concept domain should be reviewed to determine whether it needs a "ConceptualSpaceForClassCode" property to link to a RIM classCode.

Definition:

Description: Types of insurance coverage legal documentation to cover healthcare costs.

Examples:

• Automobile

• Extended healthcare

• Worker's compensation

Definition:

Definition: Set of codes indicating the type of insurance policy. Insurance, in law and economics, is a form of risk management primarily used to hedge against the risk of potential financial loss. Insurance is defined as the equitable transfer of the risk of a potential loss, from one entity to another, in exchange for a premium and duty of care. A policy holder is an individual or an organization enters into a contract with an underwriter which stipulates that, in exchange for payment of a sum of money (a premium), one or more covered parties (insureds) is guaranteed compensation for losses resulting from certain perils under specified conditions. The underwriter analyzes the risk of loss, makes a decision as to whether the risk is insurable, and prices the premium accordingly. A policy provides benefits that indemnify or cover the cost of a loss incurred by a covered party, and may include coverage for services required to remediate a loss. An insurance policy contains pertinent facts about the policy holder, the insurance coverage, the covered parties, and the insurer. A policy may include exemptions and provisions specifying the extent to which the indemnification clause cannot be enforced for intentional tortious conduct of a covered party, e.g., whether the covered parties are jointly or severably insured.

Discussion: In contrast to programs, an insurance policy has one or more policy holders, who own the policy. The policy holder may be the covered party, a relative of the covered party, a partnership, or a corporation, e.g., an employer. A subscriber of a self-insured health insurance policy is a policy holder. A subscriber of an employer sponsored health insurance policy is holds a certificate of coverage, but is not a policy holder; the policy holder is the employer. See CoveredRoleType.

Definition:

Definition: Set of codes indicating the type of health insurance policy that covers health services provided to covered parties. A health insurance policy is a written contract for insurance between the insurance company and the policyholder, and contains pertinent facts about the policy owner (the policy holder), the health insurance coverage, the insured subscribers and dependents, and the insurer. Health insurance is typically administered in accordance with a plan, which specifies (1) the type of health services and health conditions that will be covered under what circumstances (e.g., exclusion of a pre-existing condition, service must be deemed medically necessary; service must not be experimental; service must provided in accordance with a protocol; drug must be on a formulary; service must be prior authorized; or be a referral from a primary care provider); (2) the type and affiliation of providers (e.g., only allopathic physicians, only in network, only providers employed by an HMO); (3) financial participations required of covered parties (e.g., co-pays, coinsurance, deductibles, out-of-pocket); and (4) the manner in which services will be paid (e.g., under indemnity or fee-for-service health plans, the covered party typically pays out-of-pocket and then file a claim for reimbursement, while health plans that have contractual relationships with providers, i.e., network providers, typically do not allow the providers to bill the covered party for the cost of the service until after filing a claim with the payer and receiving reimbursement).

Definition:

Definition: A set of codes used to indicate coverage under a program. A program is an organized structure for administering and funding coverage of a benefit package for covered parties meeting eligibility criteria, typically related to employment, health, financial, and demographic status. Programs are typically established or permitted by legislation with provisions for ongoing government oversight. Regulations may mandate the structure of the program, the manner in which it is funded and administered, covered benefits, provider types, eligibility criteria and financial participation. A government agency may be charged with implementing the program in accordance to the regulation. Risk of loss under a program in most cases would not meet what an underwriter would consider an insurable risk, i.e., the risk is not random in nature, not financially measurable, and likely requires subsidization with government funds.

Discussion: Programs do not have policy holders or subscribers. Program eligibles are enrolled based on health status, statutory eligibility, financial status, or age. Program eligibles who are covered parties under the program may be referred to as members, beneficiaries, eligibles, or recipients. Programs risk are underwritten by not for profit organizations such as governmental entities, and the beneficiaries typically do not pay for any or some portion of the cost of coverage. See CoveredPartyRoleType.

Definition:

A type of Act representing any transaction between two accounts whose value is measured in monetary terms.

Examples:

• patient account transaction

• encounter accounttransaction

• cost center transaction

Property:   ConceptualSpaceForClassCode: ActClass.XACT

Definition:

Description: Types of provision(s) made for reimbursing for the deliver of healthcare services and/or goods provided by a Provider for one or more occurrence or over a specified period.

Examples:

• Contract

• Rostering

• Capitation

Definition:

Description: Types of operations that may be performed on objects. Here, objects are broadly understood as information system-related entities (e.g., devices, files, records, tables, processes, programs, domains) containing or receiving information.

Examples:

• Create

• Update

• Delete

Open Issue: This is too restrictive to deal with what CBCC wants.

Property:   ConceptualSpaceForClassCode: ActClass.CACT

Definition:

Description: Types of operations that may accomplish access of information. Here, objects are broadly understood as information system-related entities (e.g., devices, files, records, tables, processes, programs, domains) containing or receiving information.

Examples:

• Query

• Search

• Transport

• Send

• Receive

Property:   ConceptualSpaceForClassCode: ActClass.CACT

Definition:

Description: Types of operations that may accomplish collection or related management of information. Here, objects are broadly understood as information system-related entities (e.g., devices, files, records, tables, processes, programs, domains) containing or receiving information.

Examples:

• Create

• Store

• Archive

Property:   ConceptualSpaceForClassCode: ActClass.CACT

Definition:

Description: Types of operations that may accomplish disclosure of information. Here, objects are broadly understood as information system-related entities (e.g., devices, files, records, tables, processes, programs, domains) containing or receiving information.

Examples:

• Disclose

• Forward

• Publish

Property:   ConceptualSpaceForClassCode: ActClass.CACT

Definition:

Description: Types of operations that may accomplish usage of information. Here, objects are broadly understood as information system-related entities (e.g., devices, files, records, tables, processes, programs, domains) containing or receiving information.

Examples:

• Activate

• Release

• Execute Read

• Display

• Update

• Append

• Amend

Property:   ConceptualSpaceForClassCode: ActClass.CACT

Definition:

Description: Issue management types that dealing with detected issue observations.

Rationale: Allows for consistent specification and interpretation of issue management.

Definition:

Includes coded types of actions that can be taken by a supervising entity in response to inappropriate action (or inaction) on the part of a supervised entity.

Property:   ConceptualSpaceForClassCode: ActClass.DISPACT

Definition:

Description: List of broad catagorizations of clinical event records.

Examples:

• Allergies
• Drugs
• Referrals

Property:   ConceptualSpaceForClassCode: ActClass.LIST

Definition:

Description:Lists of high-level categorizations for clinical coded observations that do not require numeric values with a specific unit of measure.

Examples:

• Symptoms
• History
• Observations

Property:   ConceptualSpaceForClassCode: ActClass.LIST

Definition:

Description: of high-level categorization for clinical non-laboratory and non-diagnostic image measured observations with numeric values and specific units of measure.

Examples:

• Vital Signs
• Physiological Measurements
• Procedure Results

Property:   ConceptualSpaceForClassCode: ActClass.LIST

Definition:

Description: Describes types of criteria used when making observations, conducting procedures, and substance administrations.

Examples:

• medications

• immunizations

Property:   ConceptualSpaceForClassCode: ActClass.ACT

Definition:

Description: of procedure used for evaluating a precondition, goal, or trigger.

Examples:

• some radiology procedures

• respiratory therapy

• physical therapy

Property:   ConceptualSpaceForClassCode: ActMood.EVN.CRT

Definition:

Description: Type of substance administration used for evaluating a precondition, goal, or trigger.

Examples:

• other substance administrations

• respiratory therapy

• immunizations

Property:   ConceptualSpaceForClassCode: ActMood.EVN.CRT

Definition:

Description: of observation used for evaluating a precondition, goal, or trigger.

Examples:

• age-based criteria

• diagnostic-based criteria

• simple observation-based criteria (vital signs)

Property:   ConceptualSpaceForClassCode: ActMood.EVN.CRT

Definition:

Description: Type of observation used in lab for evaluating reference ranges.

Examples:

• age-based criteria

• sex-based criteria

• condition-based criteria

Property:   ConceptualSpaceForClassCode: ActMood.EVN.CRT

Definition:

Concepts that identify the type or nature of exposure interaction. Examples include "household", "care giver", "intimate partner", "common space", "common substance", etc. to further describe the nature of interaction.

Property:   ConceptualSpaceForClassCode: ActClass.EXPOS

Definition:

Codes dealing with the management of Detected Issue observations for the financial acts domain.

Property:   ConceptualSpaceForClassCode: ActClass.ACT

Definition:

Definition: Set of codes indicating the type of incident or accident.

Property:   ConceptualSpaceForClassCode: ActClass.INC

Definition:

Definition: A code specifying the particular kind of Patient Safety Incident that the Incident class instance represents.

Examples:"Medication incident", "slips, trips and falls incident".The actual value set for the domain will be determined by each (realm) implementation, whose Patient Safety terminology will be specific, although probably linked to the WHO Patient Safety Taxonomy that is currently under development

OpenIssue: This concept domain should be reviewed to determine whether it needs a "ConceptualSpaceForClassCode" property to link to a RIM classCode.

Definition:

Description: Conveyance of the type of information transfer protocol.

Property:   ConceptualSpaceForClassCode: ActClass.TRFR

Definition:

Type of invoice element that is used to assist in describing an Invoice that is either submitted for adjudication or for which is returned on adjudication results.

Property:   ConceptualSpaceForClassCode: ActClass.INVE

Definition:

Codes representing a service or product that is being invoiced (billed). The code can represent such concepts as "office visit", "drug X", "wheelchair" and other billable items such as taxes, service charges and discounts.

Definition:

OpenIssue:

Definition:

An identifying data string for healthcare procedures.

OpenIssue: This concept domain should be reviewed to determine whether it needs a "ConceptualSpaceForClassCode" property to link to a RIM classCode.

Definition:

Description:Physicians Current Procedural Terminology (CPT) Manual is a listing of descriptive terms and identifying codes for reporting medical services and procedures performed by physicians. Available for the AMA at the address listed for CPT above. These codes are found in Appendix A of CPT 2000 Standard Edition. (CPT 2000 Standard Edition, American Medical Association, Chicago, IL).

OpenIssue: This concept domain should be reviewed to determine whether it needs a "ConceptualSpaceForClassCode" property to link to a RIM classCode.

Definition:

Description:Physicians Current Procedural Terminology (CPT) Manual is a listing of descriptive terms and identifying codes for reporting medical services and procedures performed by physicians. Available for the AMA at the address listed for CPT above. These codes are found in Appendix A of CPT 2000 Standard Edition. (CPT 2000 Standard Edition, American Medical Association, Chicago, IL).

OpenIssue: This concept domain should be reviewed to determine whether it needs a "ConceptualSpaceForClassCode" property to link to a RIM classCode.

Definition:

Description:Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes are procedure identifying codes. HCPCS is Health Care Finance AdministrationaTMs (HFCA) coding scheme to group procedures performed for payment to providers. contains codes for medical equipment, injectable drugs, transportation services, and other services not found in CPT4.

OpenIssue: This concept domain should be reviewed to determine whether it needs a "ConceptualSpaceForClassCode" property to link to a RIM classCode.

Definition:

Description:International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS) are procedure identifying codes. ICD-10-PCS describes the classification of inpatient procedures for statistical purposes.

OpenIssue: This concept domain should be reviewed to determine whether it needs a "ConceptualSpaceForClassCode" property to link to a RIM classCode.

Definition:

Description:International Classification of Diseases, 9th Revision, Procedure Coding System (ICD-9-PCS) are procedure identifying codes. ICD-9-PCS describes the classification of inpatient procedures for statistical purposes.

OpenIssue: This concept domain should be reviewed to determine whether it needs a "ConceptualSpaceForClassCode" property to link to a RIM classCode.

Definition:

Description: Types of tax associated with billable services or products.

Examples:

• Provincial or State sales tax

• Harmonized sales tax

• Federal sales tax

Definition:

Description:External value set for accommodation types used in the U.S. Health Care Financing Administration (HCFA) Common Procedure Coding System (HCPCS) including modifiers.

OpenIssue: This concept domain should be reviewed to determine whether it needs a "ConceptualSpaceForClassCode" property to link to a RIM classCode.

Definition:

Description: Types of summary information that can be reported by queries dealing with Statement of Financial Activity (SOFA). The summary information is generally used to help resolve balance discrepancies between providers and payors.

Examples:

• number and total value of payable items;

• number and value of same period nullify items;

• number and value of prior nullify;

• number of non-payable nullify items;

• number of pending items;

• number of rejected items;

• number of adjudicated to zero items;

• reimbursement items (e.g., pay patient)

• Adjudicated non-payee payable prior-period electronic amount

• Adjudicated nullified prior-period electronic amount

• Adjudicated refused prior-period electronic amount

Definition:

Description: Types of grouping of invoice elements (totals, sub-totals), reported through a Payment Advice or a Statement of Financial Activity (SOFA). The code can represent summaries by day, location, payee and other cost elements such as bonus, retroactive adjustment and transaction fees.

Definition:

Description: Types of invoice element that is used to assist in describing an Invoice that is either submitted for adjudication or for which is returned on adjudication results.

Invoice elements of this type signify a grouping of one or more children (detail) invoice elements. They do not have intrinsic costing associated with them, but merely reflect the sum of all costing for its immediate children invoice elements.

Examples:

• CPINV - Clinical product invoice

• CSINV- Clinical service invoice

• RXDINV - Drug invoice

• RXCINV - Compound invoice

• CSPINV - Combined service and clinical product invoice

Definition:

Description: Types of responses that will occur as a result of the adjudication of an electronic invoice at a summary level and provides guidance on interpretation of the referenced adjudication results.

Examples:

• Re-bill for the professional fee

• Good faith override

• Wasted Drug

Definition:

Provides codes associated with ActClass value of LIST (working list)

Property:   ConceptualSpaceForClassCode: ActClass.LIST

Definition:

Description:Describes the high level classification of professional services for grouping.

Examples:Education, Counseling, Surgery, etc.

OpenIssue: This concept domain should be reviewed to determine whether it needs a "ConceptualSpaceForClassCode" property to link to a RIM classCode.

Definition:

Codes used to identify different types of 'duration-based' working lists. Examples include "Continuous/Chronic", "Short-Term" and "As-Needed".

Definition:

Definition:A collection of concepts that identifies different types of 'duration-based' mediation working lists.

Examples:"Continuous/Chronic" "Short-Term" and "As Needed"

Definition:

Description: Identifies types of monitoring programs such as tracking specified medication prescribing e.g. narcotic(s), identifying investigational studies or identifying programs regarding reimbursement or prescribing privileges.

Definition:

Description:Concepts representing indications (reasons for clinical action) other than diagnosis and symptoms.

Property:   ConceptualSpaceForClassCode: ActClass.ACT

Definition:

The type of order that was fulfilled by the clinical service

Property:   ConceptualSpaceForClassCode: ActClass.ACT

Definition:

Description:Types of policies that further specify the ActClassPolicy value set.

Property:   ConceptualSpaceForClassCode: ActClass.POLICY

Definition:

Description:Specifies the type of consent directive indicated by an ActClassPolicy e.g., a 3rd party authorization to disclose or consent for a substitute decision maker (SDM) or a notice of privacy policy. Sibling to ActPrivacyPolicyType and Child of ActPolicyType.

Definition:

Description:Types of privacy policies that further specify the ActClassPolicy value set e.g. override policy, minor's rights to mask sensitive information policy, opt-in, opt-out policy.

Definition:

Description: An identifying code for healthcare interventions/procedures.

• immunization
• appendectomy
• physiotherapy

Property:   ConceptualSpaceForClassCode: ActClass.PROC

Definition:

Definition: An identifying code for billable services, as opposed to codes for similar services used to identify them for functional purposes.

OpenIssue: This concept domain should be reviewed to determine whether it needs a "ConceptualSpaceForClassCode" property to link to a RIM classCode.

Definition:

OpenIssue: This concept domain should be reviewed to determine whether it needs a "ConceptualSpaceForClassCode" property to link to a RIM classCode.

Definition:

Definition: An identifying code for billable medical services, as opposed to codes for similar services to identify them for clinical purposes.

OpenIssue: This concept domain should be reviewed to determine whether it needs a "ConceptualSpaceForClassCode" property to link to a RIM classCode.

Definition:

Definition: An identifying code for billable services that are not medical procedures, such as social services or governmental program services.

Example: Building a wheelchair ramp, help with groceries, giving someone a ride, etc.

OpenIssue: This concept domain should be reviewed to determine whether it needs a "ConceptualSpaceForClassCode" property to link to a RIM classCode.

Definition:

Chemical reactions in the widest sense of the word.

Examples: Transcription (creating mRNA from a DNA gene), translation (creating a protein from mRNA), cleavage (hydrolysis of a peptide), substitution (replacing an element or residue with another, such as in glycosylation, phosphorylation), addition (adding a residue to a double bond), receptor binding.

Definition:

Description:An identifying code for oral health interventions/procedures.

OpenIssue: This concept domain should be reviewed to determine whether it needs a "ConceptualSpaceForClassCode" property to link to a RIM classCode.

Definition:

Description: Concept domain which includes those ActProcedureCodes which are appropriate for ordering.

Examples:

• physical therapies

• excisions

• surgery

Property:   ConceptualSpaceForClassCode: ActClass.PROC

Definition:

Description: Denotes the specific professional service that has been performed. This is obtained from the professional service catalog pertaining to the discipline of the health service provider.

Examples:

• adjustment of hearing aid

• excision of skin lesion

• stitching skin lacerations

Definition:

Description: Used to further classify the type of specimen collection procedure being documented.

Examples:

• Venipuncture

• Swab

• Biopsy

Property:   ConceptualSpaceForClassCode: ActClass.SPECCOLLECT

Definition:

Description: Describes the type of substance administration being performed. This should not be used to carry codes for identification of products. Use an associated role or entity to carry such information.

Property:   ConceptualSpaceForClassCode: ActClass.SBADM

Definition:

The introduction of ??? with the intent of stimulating an immune response, aimed at preventing subsequent infections by more viable agents.

Definition:

Acts of producing a substance by processing input material in any way thus deriving the product substance from the inputs

Examples: Fermentation, filtration, separation, extraction, or any complex procedure involving multiple such steps.

UsageNotes: This domain may involve molecular interactions as components, but substance derivation - even if implementing a single defined reaction on the molecular level - implies not only that reaction but the methods and devices by which to induce that reaction.

Definition:

Description: In addition to the class code, further defines the type of substance extraction.

Examples:

• excision

• surgical

• passive

Definition:

Description: Defines the type of blood donation.

Examples:

• autologous

• directed

• volunteer

Definition:

Description: A type of act that indicates the action taken by a practitioner or other responsible party in response to the reaction/event that is reported in the ICSR.

Examples:

• failing device replaced

• medication stopped

• medication dose adjusted

Property:   ConceptualSpaceForClassCode: ActClass.ACT

Definition:

Description: A code further classifying the type of record organizer. Used with the ActClassRecordOrganizer ActClass concept domain.

Examples:

• CDA R2

• Electrolytes Battery

• Specimen Cluster

Property:   ConceptualSpaceForClassCode: ActClass._ActClassRecordOrganizer

Definition:

A context representing a grouped commitment of information to the EHR. It is considered the unit of modification of the record, the unit of transmission in record extracts, and the unit of attestation by authorizing clinicians.

Examples: document; authentication unit; transmission unit.

Property:   ConceptualSpaceForClassCode: ActClass.COMPOSITION

Definition:

The kind of document. Possible values: discharge summary, progress note, Oncology note, etc.

Property:   ConceptualSpaceForClassCode: ActClass.DOC

Definition:

Description:Identifies the type of document that was attached to support the processing of claims, adjudication decision determination or extensions to coverage.

Property:   ConceptualSpaceForClassCode: ActClass.DOC

Definition:

Description:Contrains the type of attachment (document, XRAY, bit map image, etc.) included to support a healthcare claim. Vocabulary bound to this domain should be a specification for the type of document (i.e. WCB First Report of Acccident - Form 8).

Definition:

Description:Identifies the type of document that is used to support a request which requires special authorization. Example values in this concept domain could be: coverage extensions, step therapy, medical report, lab result, etc.

Definition:

Description: A type of document that has information related to the investigation of an adverse event or product problem report.

Examples:

• Autopsy report

• toxicology report

• clinical journal article

Property:   ConceptualSpaceForClassCode: ActClass.DOC

Definition:

Code identifying the type of identification document (e.g. passport, drivers license)

Implementation Note:The proposal called for a domain, but a code was also provided. When codes are available for the value set the code IDENTDOC (identity document) will be used as the headcode for the specializable value set.

OpenIssue: This concept domain should be reviewed to determine whether it needs a "ConceptualSpaceForClassCode" property to link to a RIM classCode.

Definition:

Description: Information type for which a provider is requesting routing of health information. This could include messaging of results or documents especially in the context of a specific service delivery location.

Examples:

• Diagnostic Image Interpretations

• Lab Test Results

• Electrocardiogram Reports

Property:   ConceptualSpaceForClassCode: ActClass.DOC

Definition:

Definition:Indicates the set of information types which may be manipulated or referenced, such as for recommending access restrictions.

Property:   ConceptualSpaceForClassCode: ActClass.DOC

Definition:

Indicates the types of documents that can be associated with a medication or group of medications.

Examples include: Patient monographs, Provider monographs, Drug protocols, etc.

Definition:

Description:

A type of documentation that is used to convey information about a product or an aspect of its life as a product - ranging from production to disposition.

Examples:

• Bill of lading

• product label

• Report of Product Disposal

Property:   ConceptualSpaceForClassCode: ActClass.DOC

Definition:

A type of document used to represent a health quality measure (aka eMeasure).

Definition:

Description:Constrains vocabulary to that which describes the type of documents that can be attached to a financial transaction such as a Special Authorization Request.

Example values under this concept domain could be: drug, device, service, etc.

Property:   ConceptualSpaceForClassCode: ActClass.DOC

Definition:

Description: Further defines the type of grouping of orders or events. This concept domain is intended to be used with the GROUPER Act class code.

Examples:

• requisition

• pre-coordinated order set

• custom order set

Property:   ConceptualSpaceForClassCode: ActClass.GROUPER

Definition:

Description: A type of concept that is used within adverse event and product problem reporting to organize data - often clinical in nature - provided for an investigative subject or other party within the scope of the investigation.

Examples:

• Medical history

• previous drug reactions

• immunization history

Property:   ConceptualSpaceForClassCode: ActClass.CATEGORY

Definition:

Description: Container of clinical statements. Navigational. No semantic content. Knowledge of the section code is not required to interpret contained observations. Represents a heading in a heading structure, or "container tree".

Examples: category; document section; document body.

Property:   ConceptualSpaceForClassCode: ActClass.CONTAINER

Definition:

A type of document section (specialization of ActClass "DOCSECT").

Property:   ConceptualSpaceForClassCode: ActClass.DOCSECT

Definition:

A type of document section within a health quality measure (aka eMeasure), used to cluster the various parts of the eMeasure into a more human navigable format.

Definition:

This is the domain of registry types. Examples include Master Patient Registry, Staff Registry, Employee Registry, Tumor Registry.

Property:   ConceptualSpaceForClassCode: ActClass.REG

Definition:

Description:Concepts representing the categorization of health services available at a particular delivery location site.

Examples:

• anesthetic service
• colonoscopy service
• orthopedic service

Definition:

Description: Further defines the type of supply for order or distribution.

Examples:

• central supply

• materials management

• nurse station supply

Property:   ConceptualSpaceForClassCode: ActClass.SPLY

Definition:

Definition:Identifies types of dispensing events.

Definition:

Description: Financial Acquisition Terms: categorizations of acquisition terms for a product.

Types of method a product can be obtained for use by the subject of the supply act (e.g. patient). Product examples are consumable or durable goods.

Examples:

• Loan

• Rent

• Sale

Property:   ConceptualSpaceForClassCode: ActClass.SPLY

Definition:

Description: A type of activity that takes place during the life of a product as it moves from the point of production to the point of consumption, use, or disposition (most notably in the case of contaminated products). It will be possible for concepts at different levels of granularity to be included.

Examples:

• Manufacture

• paint

• wholesale

• dispose

Property:   ConceptualSpaceForClassCode: ActClass.ACT

Definition:

Description: A task or action that a user may perform in a clinical information system

Examples:

• medication order entry
• laboratory test results review
• problem list entry

Property:   ConceptualSpaceForClassCode: ActClass.ACT

Definition:

Characterizes how a transportation act was or will be carried out.

Examples: Via private transport, via public transit, via courier.

Property:   ConceptualSpaceForClassCode: ActClass.TRNS

Definition:

Definition: Characterizes how a patient was or will be transported to the site of a patient encounter.

Examples: Via ambulance, via public transit, on foot.

Definition:

Description: Different types that are used to organize and classify product related investigations.

Examples:

• Original source investigation
• Secondary party investigation
• Report to regulatory authority

Definition:

DEA schedule for a drug.

OpenIssue: This concept domain should be reviewed to determine whether it needs a "ConceptualSpaceForClassCode" property to link to a RIM classCode.

Definition:

Description:Accommodation type. In Intent mood, represents the accommodation type requested. In Event mood, represents accommodation assigned/used. In Definition mood, represents the available accommodation type.

Property:   ConceptualSpaceForClassCode: ActClass.ACCM

Definition:

The trigger event referenced by the Control Act instance. Values are drawn from the available trigger events used in the release of HL7 identified by the versionCode.

Property:   ConceptualSpaceForClassCode: ActClass.CACT

Definition:

Description: Trigger events associated with laboratory results.

Examples:

• Lab result activate

• Lab result complete

• Lab result abort

Property:   ConceptualSpaceForClassCode: ActClass.CACT

Definition:

Description: Trigger events associated with specimen process steps.

Examples:

• Specimen process step activate

• Specimen process step complete

• Specimen process step abort

Property:   ConceptualSpaceForClassCode: ActClass.CACT

Definition:

Definition:

Description: The activity of businesses operating in the manufacture and distribution of products.

Examples:

• manufacture

• repack

• import

Property:   ConceptualSpaceForClassCode: ActClass.ACT

Definition:

Description: The broad activity of businesses operating in the distribution of products, the general act of making a product available to the public.

Examples:

• Marketing, (this is required as a singleton value set, as there may be no other use case for this than to distinguish one Act of handling products from other Acts, such as manufacturing.)

Property:   ConceptualSpaceForClassCode: ActClass.ACT

Definition:

Identifies the kinds of observations that can be performed

Property:   ConceptualSpaceForClassCode: ActClass.OBS

Definition:

Definition:Identifies what type of issue detected during occurrence of an act (e.g. unrecognized identifiers, drug-drug contraindications, drug-allergy alerts).

Examples:

• High dosage alert

• Conditional element missing

• Timing detected issue

Property:   ConceptualSpaceForClassCode: ActClass.ALRT

Definition:

Identifies types of detected issues for Act class "ALRT" for the financial acts domain.

OpenIssue: This concept domain should be reviewed to determine whether it needs a "ConceptualSpaceForClassCode" property to link to a RIM classCode.

Definition:

Identifies types of issues detected regarding the performance of a clinical action on a patient.

OpenIssue: This concept domain should be reviewed to determine whether it needs a "ConceptualSpaceForClassCode" property to link to a RIM classCode.

Definition:

Proposed therapy may be contraindicated or ineffective based on an existing or recent drug therapy

OpenIssue: This concept domain should be reviewed to determine whether it needs a "ConceptualSpaceForClassCode" property to link to a RIM classCode.

Definition:

Identifies the type of verification investigation being undertaken with respect to the subject of the verification activity.

Examples:

1. Verification of eligibility for coverage under a policy or program - aka enrolled/covered by a policy or program

2. Verification of record - e.g., person has record in an immunization registry

3. Verification of enumeration - e.g. NPI

4. Verification of Board Certification - provider specific

5. Verification of Certification - e.g. JAHCO, NCQA, URAC

6. Verification of Conformance - e.g. entity use with HIPAA, conformant to the CCHIT EHR system criteria

7. Verification of Provider Credentials

8. Verification of no adverse findings - e.g. on National Provider Data Bank, Health Integrity Protection Data Base (HIPDB)

Property:   ConceptualSpaceForClassCode: ActClass.VERIF

Definition:

Description:Provides a categorization for annotations recorded directly against the patient

Property:   ConceptualSpaceForClassCode: ActClass.OBS

Definition:

An Act which characterizes a Privilege can have additional observations to provide a finer definition of the requested or conferred privilege. This domain describes the categories under which this additional information is classified.

Property:   ConceptualSpaceForClassCode: ActClass.OBS

Definition:

This domain includes observations used to characterize a privilege, under which this additional information is classified.

Examples:A privilege to prescribe drugs has a RESTRICTION that excludes prescribing narcotics; a surgical procedure privilege has a PRE-CONDITION that it requires prior Board approval.

OpenIssue: This concept domain should be reviewed to determine whether it needs a "ConceptualSpaceForClassCode" property to link to a RIM classCode.

Definition:

Description:An access control object used to manage permissions and capabilities of users within information systems. (See HL7 RBAC specification fo examples of thes objects.)

OpenIssue: This concept domain should be reviewed to determine whether it needs a "ConceptualSpaceForClassCode" property to link to a RIM classCode.

Definition:

Definition: Indicates the class of actions taken with regard to a substance administration related adverse event. This characterization offers a judgment of the practitioner"s response to the patient"s problem.

Examples: Example values include dose withdrawn, dose reduced, dose not changed.

NOTE: The concept domain is currently supported by a value set created by the International Conference on Harmonization

OpenIssue: This concept domain should be reviewed to determine whether it needs a "ConceptualSpaceForClassCode" property to link to a RIM classCode.

Definition:

Categorization of types of observation that captures a person's age as a numeric quantity.

Definition:

Used in a patient care message to report and query simple clinical (non-lab) observations.

OpenIssue: This concept domain should be reviewed to determine whether it needs a "ConceptualSpaceForClassCode" property to link to a RIM classCode.

Definition:

Description: Identifies the type for a clinical observation whose value is expressed as a code.

Examples:

• Home support level

• Tumor staging

• abdominal pain characteristic

Definition:

Description: Represents the components of a coded clinical observation.

Examples:

• ability to articulate

• ability to chop food

• ability to crouch

Definition:

Identifies the types of diagnostic image.

Examples: Echocardiogram, electocardiogram, X-ray.

Definition:

OpenIssue: This concept domain should be reviewed to determine whether it needs a "ConceptualSpaceForClassCode" property to link to a RIM classCode.

Definition:

OpenIssue: This concept domain has no valid description.

Property:   ConceptualSpaceForClassCode: ActClass.OBS

Definition:

OpenIssue: This concept domain should be reviewed to determine whether it needs a "ConceptualSpaceForClassCode" property to link to a RIM classCode.

Definition:

FDA label data

OpenIssue: This concept domain should be reviewed to determine whether it needs a "ConceptualSpaceForClassCode" property to link to a RIM classCode.

Definition:

Description:Describes the supporting information for financial transactions such as a Special Authorization Request.

Example values under this concept domain could be: height, weight, duration of disease, site of fistula, etc.

This concept domain is intended to be used as part of a code/value pair within a generic structure that would convey ANY sort of information or proof of criteria that is needed to support a special authorization request.

Definition:

Description: Identifies the kinds of genetic observations that can be performed.

Definition:

Description: A type of observation on an investigative subject or a related entity that might be collected to provide the medical and social context for an adverse event report.

Examples:

• Diagnosis

• laboratory result

• autopsy determined cause of death

Definition:

Description: Types of observations which describe characteristics of the immunization material.

Definition:

Definition:

Description: Concepts that define the primary orientation of a product related investigation.

Examples:

• Product defect

• adverse event

OpenIssue:

Property:   ConceptualSpaceForClassCode: ActClass.ACT

Definition:

Description: Includes those concepts that are provided to justify the fact that an adverse event or product problem is required to be reported in an expedited fashion.

Property:   ConceptualSpaceForClassCode: ActClass.INVSTG

Definition:

Description: Includes relevant pieces of information about a product or its process of creation. The vocabulary domain is used to characterize products when they are cited in adverse event or product problem reports.

Examples:Weight, color, dimensions.

Property:   ConceptualSpaceForClassCode: ActClass.INVSTG

Definition:

Categorization of types of observation that capture a knowledge subtopic which might be treatment, etiology, or prognosis.

Definition:

Categorization of types of observation that capture the main clinical knowledge subject which may be a medication, a laboratory test, a disease.

Definition:

Identifies types of observations that can be made about a particular drug or medication.

Definition:

Description:To allow queries to specify useful information about the age of the patient without disclosing possible protected health information.

OpenIssue: This concept domain should be reviewed to determine whether it needs a "ConceptualSpaceForClassCode" property to link to a RIM classCode.

Definition:

Description:Dianostic procedures ordered or performed to evaluate whether a sensitivity to a substance is present. This test may be associated with specimen collection and/or substance administration challenge actiivities.

Example:Skin tests and eosinophilia evaluations.

OpenIssue: This concept domain should be reviewed to determine whether it needs a "ConceptualSpaceForClassCode" property to link to a RIM classCode.

Definition:

Indicates the type of allergy test performed or to be performed. E.g. the specific antibody or skin test performed

OpenIssue: This concept domain should be reviewed to determine whether it needs a "ConceptualSpaceForClassCode" property to link to a RIM classCode.

Definition:

Description: A code used to further identify the type of case status observation. Used with the OBS ActClass.

Examples:

• Clinical status

• Administrative status

• Reporting status

Definition:

Description:A kind of observation that allows a Secondary Observation (source act) to assert (at various levels of probability) that the target act of the association (which may be of any type of act) is implicated in the etiology of another observation that is named as the subject of the Secondary Observation

Example:Causality assertions where an accident is the cause of a symptom; predisposition assertions where the genetic state plus environmental factors are implicated in the development of a disease; reaction assertions where a substance exposure is associated with a finding of wheezing.

OpenIssue: This concept domain should be reviewed to determine whether it needs a "ConceptualSpaceForClassCode" property to link to a RIM classCode.

Definition:

Description: Identifies the individual coordinate in the coordinate system inclusive of any transformations or projections.

Examples: meridian, range, township, longitude, latitude, lot, block, etc.

Definition:

Description: Identifies the coordinate system inclusive of any transformation projections.

Definition:

Definition:

The set of observation type concepts that can be used to express pre-conditions to a particular dosage definition.

Rationale: Used to constrain the set of observations to those related to the applicability of a dosage, such as height, weight, age, pregnancy, liver function, kidney function, etc. For example, in drug master-file type records indicating when a specified dose is applicable.

OpenIssue: This concept domain should be reviewed to determine whether it needs a "ConceptualSpaceForClassCode" property to link to a RIM classCode.

Definition:

OpenIssue: This concept domain should be reviewed to determine whether it needs a "ConceptualSpaceForClassCode" property to link to a RIM classCode.

Definition:

Includes all codes defining types of indications such as diagnosis, symptom and other indications such as contrast agents for lab tests

OpenIssue: This concept domain should be reviewed to determine whether it needs a "ConceptualSpaceForClassCode" property to link to a RIM classCode.

Definition:

Description: Types of sensitivity caused by an exposure to a substance which results in an abnormal immunologic or non-immunologic response.

Examples:

• Food allergy
• Environmental allergy
• Fod intolerance

Definition:

Description: Used to further classify the type of investigation being documented. This concept domain is intended to be used with the INVSTG Act class code.

Examples:

• Public health case investigation

• Safety investigation

• Surveillance investigation

Definition:

Distinguishes the kinds of coded observations that could be the trigger for clinical issue detection. These are observations that are not measurable, but instead can be defined with codes. Coded observation types include: Allergy, Intolerance, Medical Condition, Pregnancy status, etc.

Definition:

Distinguishes between the kinds of measurable observations that could be the trigger for clinical issue detection. Measurable observation types include: Lab Results, Height, Weight.

OpenIssue: This concept domain should be reviewed to determine whether it needs a "ConceptualSpaceForClassCode" property to link to a RIM classCode.

Definition:

Description: A set of codes specifying the type of Laboratory Report.

Examples:

• Hematology reports

• Chemistry reports

• Blood gas reports

Property:   ConceptualSpaceForClassCode: ActClass.OBS

Definition:

Description: Identifies the type of observations that can be ordered.

Examples:

• lab tests

• diagnostic imaging

• device summary

Property:   ConceptualSpaceForClassCode: ActClass.OBS

Definition:

Description: Identifies the ordered lab test. Also known as the lab order code or test code.

Examples:

• red blood cell count

• components of a chemistry panel

• microbiology sensitivity testing

Property:   ConceptualSpaceForClassCode: ActClass.OBS

Definition:

Description: A code used to further identify the type of Outbreak Extent Observation. Used with the OBS ActClass.

Examples:

• Geographic extent

• Jurisdictional extent

Definition:

Description: Identifies the type of position accuracy carried in observation value.

Definition:

Definition:Identifies the kinds of public health cases. Used only with the CASE Act class code.

Examples of types of public health cases includes reportable disease cases, radiation exposure cases and chemical exposure cases.

Definition:

Description:

Used to further classify the type of Outbreak being documented. This concept domain is intended to be used with the OUTB Act class code.

Examples:

• Epidemic

• Pandemic

• Endemic

Definition:

Codes used to define various metadata aspects of a health quality measure (specialization of ActClass "OBS").

Definition:

Definition: An observation related to a query response.

Example:The degree of match or match weight returned by a matching algorithm in a response to a query.

OpenIssue: This concept domain should be reviewed to determine whether it needs a "ConceptualSpaceForClassCode" property to link to a RIM classCode.

Definition:

Description: Identifies the type of observation that can be resulted. There are some labs which are not ordered and are performed and resulted when the outcome of an ordered test meets some criteria.

Examples:

• outcomes of lab tests

• device summary

• therapeutic drug level testing

Property:   ConceptualSpaceForClassCode: ActClass.OBS

Definition:

Description: The type of lab observation being resulted. There are some lab tests which are not ordered and are performed and resulted when the outcome of an ordered test meets some criteria.

Examples:

• red blood cell count

• results of micro sensitivity testing

• Missing third example

Definition:

Definition: Identifies the type of Vision Prescription Observation that is being described.

OpenIssue: This concept domain should be reviewed to determine whether it needs a "ConceptualSpaceForClassCode" property to link to a RIM classCode.

Definition:

Indicates the type of characteristics a patient should have for a given therapy to be appropriate. E.g. Weight, Age, certain lab values, etc.

OpenIssue: This concept domain should be reviewed to determine whether it needs a "ConceptualSpaceForClassCode" property to link to a RIM classCode.

Definition:

Description: Reporting codes that are related to an immunization event.

Definition:

Observations specific to a particular prescription to express concepts that cannot be expressed via other modeling approaches.

Examples: "Patient Medication On Hand Quantity", "Patient Medication On Hand Days Supply", "Patient Expected Supply Run-out Date", "Percentage Dispensed".

Definition:

Categorization of types of observation that capture the interpretation of the result of a laboratory test in terms of normality.

Definition:

Types of measurement observations typically performed in a clinical (non-lab) setting. E.g. Height, Weight, Blood-pressure

OpenIssue: This concept domain should be reviewed to determine whether it needs a "ConceptualSpaceForClassCode" property to link to a RIM classCode.

Definition:

Description: Represents the components of a measured clinical observation.

Examples:

• the systolic and diastolic components of a blood pressure

• 24-hour urine output

• ARAC gene

Definition:

Distinguishing traits, qualities, or properties given about substances, including chemical structure (as encapsulated data in SMILES, MolFile, InChi), nucleic acid sequence, amino acid sequence, molecular sum formula; molecular mass; stereochemistry and optical activity properties; viscosity; pH, pK _a, catalytic activity, etc.

Definition:

Description: A rule set by regulators of product that somehow constrain the use of products. Regulator may be any organization with a mandate to issue such rules, regardless of level, regional, country, state, and local (e.g., an institutional Pharmaceutical and Treatment Committee.)

Examples:

• Prescription Only

• Controlled Substance Schedule II

• Standard of Practice

Property:   ConceptualSpaceForClassCode: ActClass.POLICY

Definition:

Description: An approval granted to a product by a regulatory agency or other government body.

Examples:

• Approval to sell

• Approval to initiate clinical trial

• Approval to market (i.e., advertise)

Property:   ConceptualSpaceForClassCode: ActClass.CNTRCT

Definition:

Description: Different types of research studies that may be conducted and reported on.

Examples:

• Observational
• Investigational

Property:   ConceptualSpaceForClassCode: ActClass.INVSTG

Definition:

Description: Code specifying the level within a hierarchical Act composition structure and the kind of contextual information attached to composite Acts ("containers") and propagated to component Acts within those containers. The levelCode signifies the position within such a containment hierarchy and the applicable constraints.

Examples: The "extract level" and the "folder level" must contain data about a single individual, whereas the "multiple subject level" may contain data about multiple individuals. While "extract" can originate from multiple sources, a "folder" should originate from a single source. The "composition" level usually has a single author.

Constraints: The constraints applicable to a particular level may include differing requirements for participations (e.g. patient, source organization, author or other signatory), relationships to or inclusion of other Acts, documents or use of templates. The constraints pertaining to a level may also specify the permissible levels that may be contained as components of that level. Several nested levels with the same levelCode may be permitted, prohibited (or limited). Instance of the next subordinate level are usually permitted within any level but some levels may be omitted from a model and it may be permissible to skip several layers.

Discussion: The levelCode concepts have been defined to meet specific health record transfer requirements. While these concepts are known to be applicable to some other types of transactions, they are not intended to a be a complete closed list. Options exist for other sets of orthogonal levels where required to meet a business purpose (e.g. a multiple patient communication may be subdivided by a super-ordinate level of subject areas).

Definition:

A qualitative measure of the degree of exposure to the causative agent. This includes concepts such as "low", "medium" and "high". This quantifies how the quantity that was available to be administered to the target differs from typical or background levels of the substance.

Definition:

Processing consideration and clarification codes.

Definition:

Description:codesConcepts (e.g., error, warning) specifying the urgency associated with a detected issue.

Definition:

A code distinguishing whether an Act is conceived of as a factual statement or in some other manner as a command, possibility, goal, etc.

Constraints: An Act-instance must have one and only one moodCode value.

The moodCode of a single Act-instance never changes. Mood is not state.

To describe the progression of a business activity from defined to planned to executed, etc. one must instantiate different Act-instances in the different moods and link them using ActRelationship of general type "sequel". (See ActRelationship.type.)

Discussion: The Act.moodCode includes the following notions: (1) event, i.e., factual description of an actions that occurred; (2) definition of possible actions and action plans (the master file layer); (3) intent, i.e., an action plan instantiated for a patient as a care plan or order; (4) goal, i.e., an desired outcome attached to patient problems and plans; and (5) criterion, i.e., a predicate used as

The Act.moodCode modifies the meaning of the Act class in a controlled way, just as in natural language, grammatical form of a verb modify the meaning of a sentence in defined ways. For example, if the mood is factual (event,) then the entire act object represents a known fact. If the mood expresses a plan (intent,) the entire act object represents the expectation of what should be done. The mood does not change the meaning of individual act properties in peculiar ways.

Since the mood code is a determining factor for the meaning of an entire Act object, the mood must always be known. This means, whenever an act object is instantiated, the mood attribute must be assigned to a valid code, and the mood assignment can not change throughout the lifetime of an act object.

As the meaning of an act object is factored in the mood code, the mood code affects the interpretation of the entire Act object and with it every property (attributes and associations.) Note that the mood code affects the interpretation of the act object, and the meaning of the act object in turn determines the meaning of the attributes. However, the mood code does not arbitrarily change the meaning of individual attributes.

Inert vs. descriptive properties of Acts: Acts have two kinds of act properties, inert and descriptive properties. Inert properties are not affected by the mood, descriptive properties follow the mood of the object. For example, there is an identifier attribute Act.id, which gives a unique identification to an act object. Being a unique identifier for the object is in no way dependent on the mood of the act object. Therefore, the "interpretation" of the Act.id attribute is inert with respect to the act object's mood.

By contrast, most of the Act class' attributes are descriptive for what the Act statement expresses. Descriptive properties of the Act class give answer to the questions who, whom, where, with what, how and when the action is done. The questions who, whom, with what, and where are answered by Participatons, while how and when is answered by descriptive attributes and ActRelationships. The interpretation of a descriptive attribute is aligned to the interpretation of the entire act object, and controlled by the mood.

Examples: To illustrate the effect of mood code, consider a "blood glucose" observation:

The DEFINITION mood specifies the Act of "obtaining blood glucose". Participations describe in general the characteristics of the people who must be involved in the act, and the required objects, e.g., specimen, facility, equipment, etc. involved. The Observation.value specifies the absolute domain (range) of the observation (e.g., 15-500 mg/dl.)

In INTENT mood the author of the intent expresses the intent that he or someone else "should obtain blood glucose". The participations are the people actually or supposedly involved in the intended act, especially the author of the intent or any individual assignments for group intents, and the objects actually or supposedly involved in the act (e.g., specimen sent, equipment requirements, etc.) The Observation.value is usually not specified, since the intent is not to measure blood glucose, not to measure blood glucose in a specific range. (But compare with GOAL below.)

In ORDER mood, a kind of intent, the author requests to "please obtain blood glucose". The Participations are the people actually and supposedly involved in the act, especially the placer and the designated filler, and the objects actually or supposedly involved in the act (e.g., specimen sent, equipment requirements, etc.) The Observation.value is usually not specified, since the order is not to measure blood glucose in a specific range.

In EVENT mood, the author states that "blood glucose was obtained". Participations are the people actually involved in the act, and the objects actually involved (e.g., specimen, facilities, equipment.) The Observation.value is the value actually obtained (e.g., 80 mg/dL, or <15 mg/dL.)

In event-CRITERION mood, an author considers a certain class of "obtaining blood glucose" possibly with a certain value (range) as outcome. The Participations constrain the criterion, for instance, to a particular patient. The Observation.value is the range in which the criterion would hold (e.g. > 180 mg/dL or 200?300 mg/dL.)

In GOAL mood (a kind of criterion) the author states that "our goal is to be able to obtain blood glucose with the given value (range)". The Participations are similar to intents, especially the author of the goal and the patient for whom the goal is made. The Observation.value is the range which defined when the goal is met (e.g. 80?120 mg/dl.)

Rationale: The notion of "mood" is borrowed from natural language grammar, the mood of a verb (lat. modus verbi).

The notion of mood also resembles the various extensions of the logic of facts in modal logic and logic with modalities, where the moodCode specifies the modality (fact, possibility, intention, goal, etc.) under which the Act-statement is judged as appropriate or defective.

Definition:

A non-mandated intent to perform an act. Used to record intents that are explicitly not Orders. Professional responsibility for the 'proposal' may or may not be present.

Definition:

A code or set of codes (e.g., for routine, emergency,) specifying the urgency under which the Act happened, can happen, is happening, is intended to happen, or is requested/demanded to happen.

Discussion: This attribute is used in orders to indicate the ordered priority, and in event documentation it indicates the actual priority used to perform the act. In definition mood it indicates the available priorities.

Definition:

Description: Types of priorities to determine start of an encounter.

Definition:

A code specifying the motivation, cause, or rationale of an Act, when such rationale is not reasonably representable as an ActRelationship of type "has reason" linking to another Act.

Examples: Example reasons that might qualify for being coded in this field might be: "routine requirement", "infectious disease reporting requirement", "on patient request", "required by law".

Discussion

Most reasons for acts can be clearly expressed by linking the new Act to another prior Act using an ActRelationship of type "has reason". This simply states that the prior Act is a reason for the new Act (see ActRelationship.) The prior act can then be a specific existing act or a textual explanation. This works for most cases, and the more specific the reason data is, the more should this reason ActRelationship be used instead of the reasonCode.

The reasonCode remains as a place for common reasons that are not related to a prior Act or any other condition expressed in Acts. Indicators that something was required by law or was on the request of a patient etc. may qualify. However, if that piece of legislation, regulation, or the contract or the patient request can be represented as an Act (and they usually can), the reasonCode should not be used.

Definition:

Explanatory codes that describe reasons why an Adjudicator has financially adjusted an invoice (claim).

A companion domain (ActAdjudicationInformationCode) includes information reasons which do not have a financial impact on an invoice (claim).

Example adjudication reason code is AA-CLAIM-0011 - Only Basic Procedure/Test Eligible.

Codes from this domain further rationalizes ActAdjudicationCodes (e.g. AA - Adjudicated with Adjustment), which are used to describe the process of adjudicating an invoice. For AS - Adjudicated as Submitted, there should be no specification of ActAdjudicationReason codes, as there are no financial adjustments against the invoice.

Definition:

Description: Describe why an antigen is considered to be invalid for use.

Definition:

Definition: This domain is used to document reasons for providing a billable service; the billable services may include both clinical services and social services.

Definition:

Description: May be sent to indicate one or more reasons for the performance of a billable clinical service or product, and not related or specified by a diagnosis.

Examples:

• Duplicate Therapy

• Care protocol

• Insurance requirement

Definition:

Definition: This domain is used to document why the procedure is a duplicate of one ordered/charged previously for the same patient within the same date of service and has been determined to be medically necessary.

Example: A doctor needs a different view in a chest X-Ray.

Definition:

Description: Maybe sent to indicate one or more reasons for the performance of a non clinical service or product, and not related or specified by diagnosis.

Examples:

• Fraudulent prescription

• Patient's preference

• Physiotherapy equipment

Definition:

Description: A duplicate non-clinical service or product is being re-billed.

Examples:

• Duplicate transportation required for physician visit

• Wrong size of a product

• Rebuilding wheel chair ramp due to a weather condition

Definition:

Definition: Use to convey the reason that a provider may or has accessed personal healthcare information. Typically, this involves overriding the subject's consent directives.

Definition:

Description:Represents the reason for the level of coverage provided under the policy or program in terms of the types of entities that may play covered parties based on their personal relationships or employment status.

Definition:

Description:Codes used to specify reasons or criteria relating to coverage provided under a policy or program. May be used to convey reasons pertaining to coverage contractual provisions, including criteria for eligibility, coverage limitations, coverage maximums, or financial participation required of covered parties.

Definition:

Description:Identifies the reason or rationale for coverage of a service or product based on characteristics of the provider, e.g., contractual relationship to payor, such as in or out-of-network; relationship of the covered party to the provider.

Example:In closed managed care plan, a covered party is assigned a primary care provider who provides primary care services and authorizes referrals and ancillary and non-primary care services.

Definition:

Description:Identifies the reason or rationale for coverage of a service or product based on clinical efficacy criteria or practices prescribed by the payor.

Definition:

Description:Identifies the reason or rationale for coverage of a service or product based on coverage exclusions related the risk of adverse selection by covered parties.

Definition:

Description:Identifies the reason or rationale for coverage of a service or product based on financial participation responsibilities of the covered party.

Definition:

Description:Identifies the reason or rationale for limitations on the coverage of a service or product based on coverage contract provisions.

Example:The maximum cost per unit; or the maximum number of units per period, which is typically the policy or program effective time.

Definition:

Identifies the reason or rational for why a person is eligibile for benefits under an insurance policy or progam.

Examples: A person is a claimant under an automobile insurance policy are client deceased & adopted client has been given a new policy identifier. A new employee is eligible for health insurance as an employment benefit. A person meets a government program eligibility criteria for financial, age or health status.

Definition:

Definition: Identifies the reason or rational for why a person is eligibile for benefits under an insurance policy or progam.

Examples: A person is a claimant under an automobile insurance policy are client deceased & adopted client has been given a new policy identifier. A new employee is eligible for health insurance as an employment benefit. A person meets a government program eligibility criteria for financial, age or health status.

Definition:

Description: Administration reasons for patient encounters.

Definition:

Definition:

Description: The rationale or purpose for an act relating to information management, such as archiving information for the purpose of complying with an enterprise data retention policy.

Definition:

Description: The rationale or purpose for an act relating to health information management, such as archiving information for the purpose of complying with an organization policy or jurisdictional law relating to data retention.

Definition:

Description: The rationale or purpose for an act relating to the management of personal health information, such as collecting personal health information for research or public health purposes.

Definition:

Description: Use to convey the reason that a provider may or has accessed personal healthcare information. Typically, this involves overriding the subject's consent directives.

Definition:

Description: The rationale or purpose for an act relating to the management of personal information, such as disclosing personal tax information for the purpose of complying with a court order.

Definition:

Definition:

OpenIssue:

Definition:

Indicates why a fulfiller refused to fulfill a supply order, and considered it important to notify other providers of their decision. E.g. "Suspect fraud", "Possible abuse", "Contraindicated".

(used when capturing 'refusal to fill' annotations)

Definition:

Definition:Contains domains for act reasons used in clinical research.

Definition:

Definition:Specifies the reason that an event occurred in a clinical research study.

Definition:

Definition:SSpecifies the reason that a test was performed or observation collected in a clinical research study.

Note:This set of codes are not strictly reasons, but are used in the currently Normative standard. Future revisions of the specification will model these as ActRelationships and thes codes may subsequently be retired. Thus, these codes should not be used for new specifications.

Definition:

Identifies why a specific query, request, or other trigger event occurred.

Definition:

Description:Indicates why the prescription should be suspended.

Definition:

Description:Identifies reasons for nullifying (retracting) a particular control act.

Examples:"Entered in error", "altered decision", etc.

Definition:

Description:Identifies reasons for nullifying (retracting) a particular control act.

Examples:"Entered in error", "altered decision", etc.

Definition:

Description: Indicates why a specific transaction which was requested to be undone; was not undone.

Definition:

Indicates why the ConditionaTMs status was changed to Nullified. Examples administrative error, diagnostic error.

Definition:

Description:Identifies why a change is being made to a record.

Definition:

Description:Indicates the reason the medication order should be aborted.

Definition:

Definition:A collection of concepts that indicate why the prescription should be released from suspended state.

Definition:

Definition:A collection of concepts identifying why the patient's profile is being queried.

Definition:

Definition:Identifies why the dispense event was not completed

Definition:

Definition:A collection of concepts that indicates the reason for a "bulk supply" of medication.

Definition:

Definition:Indicates why the request to transfer a prescription from one dispensing facility to another has been refused.

Definition:

Definition:A collection of concepts that identifies why a renewal prescription has been refused.

Definition:

Indicates why the act revision (status update) is being refused.

Definition:

Definition:Indicates why the requested authorization to prescribe or dispense a medication has been refused.

Definition:

Definition:A collection of concepts that indicates why the prescription should no longer be allowed to be dispensed (but can still administer what is already being dispensed).

Definition:

The reason the action was not performed, e.g. why the medication was not taken. If an action was not performed, it is often clinically important to know why the action was not taken.

Examples:Patient refused, clinically inappropriate, absolute contraindication etc.

Definition:

Code assigned to indicate the rationale for not performing an evaluation investigation on a device for which a defect has been reported.

Examples include: device received in a condition that made analysis impossible, device evaluation anticipated but not yet begun, device not made by company.

Definition:

The reason a referral was made.

Examples:Specialized Medical Assistance, Other Care Requirements.

Definition:

Description: Identifies why a request to add (or activate) a record is being refused. Examples include the receiving system not able to match the identifier and find that record in the receiving system, having no permission, or a detected issue exists which precludes the requested action.

Definition:

Description: Possible reasons generating a report providing information developed during the investigation of an adverse event or a product problem.

Examples:

• Correction
• Additional information/Follow-up
• Response to regulatory agency request

Definition:

Reasons why substitution of a substance administration request is not permitted.

Definition:

OpenIssue:

Definition:

Description: Identifies why a request to update to a record is being refused. Examples include the receiving system not able to match the identifier and find that record in the receiving system, having no permission, or a detected issue exists which precludes the requested action.

Definition:

A code specifying when in the course of an Act a precondition for the Act is evaluated (e.g., before the Act starts for the first time, before every repetition, after each repetition but not before the first, or throughout the entire time of the Act.)

Discussion: This attribute is part of the workflow control suite of attributes. An action plan is a composite Act with component Acts. In a sequential plan, each component has a sequenceNumber that specifies the ordering of the plan steps. Before each step is executed and has preconditions these conditions are tested and if the test is positive, the Act has clearance for execution. The repeatNumber may indicate that an Act may be repeatedly executed. The checkpointCode is specifies when the precondition is checked and is analogous to the various conditional statements and loop constructs in programming languages "while-do" vs. "do-while" or "repeat-until" vs. "loop-exit".

For all checkpointCodes, except "end", preconditions are being checked at the time when the preceding step of the plan has terminated and this step would be next in the sequence established by the sequenceNumber attribute.

When the checkpointCode for a criterion of a repeatable Act is "end", the criterion is tested only at the end of each repetition of that Act. When the condition holds true, the next repetition is ready for execution.

When the checkpointCode is "entry" the criterion is checked at the beginning of each repetition (if any) whereas "beginning" means the criterion is checked only once before the repetition "loop" starts.

The checkpointCode "through" is special in that it requires the condition to hold throughout the execution of the Act, even throughout a single execution. As soon as the condition turns false, the Act should receive an interrupt event (see interruptibleInd) and will eventually terminate.

The checkpointCode "exit" is only used on a special plan step that represents a loop exit step. This allows an action plan to exit due to a condition tested inside the execution of this plan. Such exit criteria are sequenced with the other plan components using the ActRelationship.sequenceNumber.

Definition:

A code specifying how concurrent Acts are resynchronized in a parallel branch construct.

Discussion: This attribute is part of the workflow control suite of attributes. An action plan is a composite Act with component Acts. In a sequential plan, each component has a sequenceNumber that specifies the ordering of the plan steps. Branches exist when multiple components have the same sequenceNumber. Branches are parallel if the splitCode specifies that more than one branch can be executed at the same time. The joinCode then specifies if and how the braches are resynchronized.

The principal re-synchronization actions are (1) the control flow waits for a branch to terminate (wait-branch), (2) the branch that is not yet terminated is aborted (kill-branch), (3) the branch is not re-synchronized at all and continues in parallel (detached branch).

A kill branch is only executed if there is at least one active wait (or exclusive wait) branch. If there is no other wait branch active, a kill branch is not started at all (rather than being aborted shortly after it is started.) Since a detached branch is unrelated to all other branches, active detached branches do not protect a kill-branch from being aborted.

Definition:

A code specifying how branches in an action plan are selected among other branches.

Discussion: This attribute is part of the workflow control suite of attributes. An action plan is a composite Act with component Acts. In a sequential plan, each component has a sequenceNumber that specifies the ordering of the plan steps. Branches exist when multiple components have the same sequenceNumber. The splitCode specifies whether a branch is executed exclusively (case-switch) or inclusively, i.e., in parallel with other branches.

In addition to exlusive and inclusive split the splitCode specifies how the pre-condition (also known as "guard conditions" on the branch) are evaluated. A guard condition may be evaluated once when the branching step is entered and if the conditions do not hold at that time, the branch is abandoned. Conversely execution of a branch may wait until the guard condition turns true.

In exclusive wait branches, the first branch whose guard conditions turn true will be executed and all other branches abandoned. In inclusive wait branches some branches may already be executed while other branches still wait for their guard conditions to turn true.

Definition:

Used to indicate that the target of the relationship will be a filtered subset of the total related set of targets.

Used when there is a need to limit the number of components to the first, the last, the next, the total, the average or some other filtered or calculated subset.

Definition:

Used to indicate that the participation is a filtered subset of the total participations of the same type owned by the Act.

Used when there is a need to limit the participations to the first, the last, the next or some other filtered subset.

Definition:

A code specifying the meaning and purpose of every ActRelationship instance. Each of its values implies specific constraints to what kinds of Act objects can be related and in which way.

Discussion: The types of act relationships fall under one of 5 categories:

1.) (De)-composition, with composite (source) and component (target)

2.) Sequel which includes follow-up, fulfillment, instantiation, replacement, transformation, etc. that all have in common that source and target are Acts of essentially the same kind but with variances in mood and other attributes, and where the target exists before the source and the source refers to the target that it links back to.

3.) Pre-condition, trigger, reason, contraindication, with the conditioned Act at the source and the condition or reason at the target.

4.) Post-condition, outcome, goal and risk, with the Act at the source having the outcome or goal at the target.

5.) A host of functional relationships including support, cause, derivation, etc. generalized under the notion of "pertinence".

Definition:

Used to enumerate the relationships between a CDA section and its contained entries.

Definition:

Description still needed

Definition:

Description still needed

Definition:

An anatomical location on an organism which can be the focus of an act.

Definition:

Description: Sites used for blood donation.

Examples:

• arm

• leg

• heel

Definition:

An anatomical location on a non-human animal which can be the focus of an act.

Definition:

An anatomical location on a human which can be the focus of an act.

Definition:

Description: The set of body locations to or through which a substance or product may be administered.

• buttock
• left upper arm
• bilateral eyes

Definition:

An anatomical location on a human of an injury or disease which is the focus of an act.

Definition:

Contains the names (codes) for each of the states in the state-machine of the RIM Act class.

Definition:

Definition:Identifies the types of substitution that may be permitted when ordering a medication, as well as those which have actually occurred during the act of dispensing.

Property:   ConceptualSpaceForClassCode: ActClass.SUBST

Definition:

A code indicating whether the Act statement as a whole, with its subordinate components has been asserted to be uncertain in any way.

Examples: Patient might have had a cholecystectomy procedure in the past (but isn't sure).

Constraints: Uncertainty asserted using this attribute applies to the combined meaning of the Act statement established by all descriptive attributes (e.g., Act.code, Act.effectiveTime, Observation.value, SubstanceAdministration.doseQuantity, etc.), and the meanings of any components.

Discussion:This is not intended for use to replace or compete with uncertainty associated with a Observation.values alone or other individual attributes of the class. Such pointed indications of uncertainty should be specified by applying the PPD, UVP or UVN data type extensions to the specific attribute. Particularly if the uncertainty is uncertainty of a quantitative measurement value, this must still be represented by a PPD<PQ> in the value and NOT using the uncertaintyCode. Also, when differential diagnoses are enumerated or weighed for probability, the UVP<CD> or UVN<CD> must be used, not the uncertaintyCode. The use of the uncertaintyCode is appropriate only if the entirety of the Act and its dependent Acts is questioned.

Note that very vague uncertainty may be thought related to negationInd, however, the two concepts are really independent. One may be very uncertain about an event, but that does not mean that one is certain about the negation of the event.

Definition:

Discussion: The hierarchical nature of these concepts shows composition. E.g. "Street Name" is part of "Street Address Line"

Definition:

The gender of a person used for adminstrative purposes (as opposed to clinical gender)

Definition:

Provides coded key words for attribute AttentionLine.keyWordText, which has data type SC.

Definition:

Definition:The domain of possible values used as the value of attention line specifications in AttentionLine directives.

Definition:

Provides coded names for attribute Batch.name, which has data type SC.

Definition:

OpenIssue:

Definition:

OpenIssue:

Definition:

One letter calendar cycle abbreviations (Temporary - remove when RoseTree is fixed)

Definition:

Two letter calendar cycle abbreviations (Temporary - remove when RoseTree is fixed)

Definition:

OpenIssue:

Definition:

Code for the method by which the public health department was made aware of the case. Includes provider report, patient self-referral, laboratory report, case or outbreak investigation, contact investigation, active surveillance, routine physical, prenatal testing, perinatal testing, prison entry screening, occupational disease surveillance, medical record review, etc.

Definition:

Code that indicates whether the disease was likely acquired outside the jurisdiction of observation, and if so, the nature of the inter-jurisdictional relationship. Possible values include not imported, imported from another country, imported from another state, imported from another jurisdiction, and insufficient information to determine.

Definition:

Code for the mechanism by which disease was acquired by the living subject involved in the public health case. Includes sexually transmitted, airborne, bloodborne, vectorborne, foodborne, zoonotic, nosocomial, mechanical, dermal, congenital, environmental exposure, indeterminate.

OpenIssue: Consider moving this attribute to Observation.

Definition:

Internet Assigned Numbers Authority (IANA) Charset Types

Definition:

Identifies how to interpret the instance of the code, codeSystem value in a set of translations. Since HL7 (or a government body) may mandate that codes from certain code systems be sent in conformant messages, other synonyms that are sent in the translation set need to be distinguished among the originally captured source, the HL7 specified code, or some future role. When this code is NULL, it indicates that the translation is an undefined type. When valued, this property must contain one of the following values:

SRC - Source (or original) code HL7 - HL7 Specified or Mandated SH - both HL7 mandated and the original code (precoordination)

There may be additional values added to this value set as we work through the use of codes in messages and determine other Use Cases requiring special interpretation of the translations.

Definition:

Describes the type of communication function that the associated entity plays in the associated transmission.

Definition:

Definition:A container intended to contain sufficient material for more than one use, but grouped or organized to provide individual access to sufficient material for a single use. Often used to ensure that the proper type and amount of material is consumed/expended for each use.

Definition:

OpenIssue:

Definition:

Values that control disclosure of information.

Example: Normal, restricted, substance abuse related.

Definition:

The type of cap associated with a container

Definition:

A material in a blood collection container that facilites the separation of of blood cells from serum or plasma

Definition:

Description:Identifies the order in which content should be processed.

Definition:

Definition:

This table contains the control codes that are used to manage the propagation and scope of a particular ActRelationship or Participation within a set of Acts.

Definition:

Countries of the world. ISO 3166, part 1, alpha-3 set.

Definition:

The currency unit as defined in ISO 4217

Definition:

Domain values for the Device.Alert_levelCode

Definition:

Identifies the current completion state of a clinical document.

Definition:

Identifies the storage status of a document.

Definition:

Description: Highest level of education a person has achieved.

Examples:

• Elementary School
• College or baccalaureate degree complete
• High School

Definition:

Provides coded names for attribute SortControl.elementName , which has data type SC.

Definition:

A code specifying the job performed by the employee for the employer. For example, accountant, programmer analyst, patient care associate, staff nurse, etc.

Definition:

A code qualifying the employment in various ways, such as, full-time vs. part time, etc.

Definition:

Industry and/or jurisdictional classification system for kind-of-work performed by an employee.

Occupation codes are intended primarily as work descriptions that are suitable for a multitude of public uses e.g., job matching, employment counseling, occupational and career guidance, and labor market information services.

Definition:

A value representing the method used by an employer to compute an employee's salary or wages.

Examples: Hourly, annual, commission

Definition:

A code used to define the employment status of the insured individual identified in UB-92 FL 58. UB-92 Form locator 64:Employment Status Code of the Insured. Can be used with Employee_Employer_statusCode in HL7. Values include Employed Full Time, Employed Part Time, Not Employed, Retired, On Active Military Duty

Definition:

A code depicting the acuity (complexity of patient care, resource intensiveness of the patient care) of a patient's medical condition upon arrival. Values may be derived from formal acuity coding schemes such as RBS.

Definition:

OpenIssue:

Definition:

A code indicating patient status as of the ending service date of the period covered on this bill, as reported in FL6, Statement Covers Period. Values such as: Discharged to home or self care; Discharged/transferred to SNF, Discharged/transferred to an intermediate care facility (ICF); Expired; Hospice-medical facility. NUBC Form Locator 22

Definition:

A code used to define the place or organization responsible for the patient immediately prior to their admission; for example, in the United States, as this is identified in UB-92 Form Locator 20, Source of Adm(ission).

Definition:

A code identifying special courtesies extended to the patient. For example, no courtesies, extended courtesies, professional courtesy, VIP courtesies.

Definition:

Classifies the Entity class and all of its subclasses. The terminology is hierarchical. At the top is this HL7-defined domain of high-level categories (such as represented by the Entity subclasses). Each of these terms must be harmonized and is specializable.

The value sets beneath are encoded in Entity.code and are drawn from multiple, frequently external, domains that reflect much more fine-grained typing.

Definition:

A value representing the specific kind of Entity the instance represents.

Examples: A medical building, a Doberman Pinscher, a blood collection tube, a tissue biopsy.

Rationale: For each Entity, the value for this attribute is drawn from one of several coding systems depending on the Entity classCode, such as living subjects (animal and plant taxonomies), chemical substance (e.g., IUPAC code), organizations, insurance company, government agency, hospital, park, lake, syringe, etc. It is possible that Entity.code may be so fine grained that it represents a single instance. An example is the CDC vaccine manufacturer code, modeled as a concept vocabulary, when in fact each concept refers to a single instance.

Definition:

Anything that essentially has the property of life, independent of current state (a dead human corpse is still essentially a living subject).

Examples: persons, animals, trees .

Property:   ConceptualSpaceForClassCode: EntityClass.LIV

Definition:

Description:Types of NonPersonLivingSubjects for the EntityClass "NLIV"

Property:   ConceptualSpaceForClassCode: EntityClass.NLIV

Definition:

Description: A categorizing and grouping mechanism for different types of animal in order to support treatment and reporting. The categories are expected to correspond to a single animal species, or to a related group of species.

Examples:

• Dog

• Reptile

• Deer

Property:   ConceptualSpaceForClassCode: EntityClass.ANM

Definition:

Types of Material for EntityClass "MAT"

Property:   ConceptualSpaceForClassCode: EntityClass.MAT

Definition:

Definition:An object used to hold other entities.

Examples:

• Test tube

• Shoe box

• Drinking glass

Property:   ConceptualSpaceForClassCode: EntityClass.CONT

Definition:

Description: Holders are containers that hold other containers or holders.

Examples:

• Tube rack

• Specimen carrier

• Tray

Property:   ConceptualSpaceForClassCode: EntityClass.HOLD

Definition:

Includes the set of codes used to identify a device that may be referred to in an ICSR report. Example code set reference is the FDA Center for Devices and Radiological Health product code list.

Example product codes include: FOZ = Catheter, Intravascular, Therapeutic, short-term less than 30 days, MOP = Rotator, Prosthetic Heart Valve.

OpenIssue: This concept domain should be reviewed to determine whether it needs a "ConceptualSpaceForClassCode" property to link to a RIM classCode.

Definition:

A substance whose therapeutic effect is produced by chemical action within the body.

OpenIssue: This concept domain should be reviewed to determine whether it needs a "ConceptualSpaceForClassCode" property to link to a RIM classCode.

Definition:

Any substance or mixture of substances manufactured, sold or represented for use in: (a) the diagnosis, treatment, mitigation or prevention of a disease, disorder, abnormal physical state, or its symptoms, in human beings or animals; (b) restoring, correcting or modifying organic functions in human beings or animals.

OpenIssue: This concept domain should be reviewed to determine whether it needs a "ConceptualSpaceForClassCode" property to link to a RIM classCode.

Definition:

Any substance which, when combined with other ingredients, delivers all or part of the therapeutic benefit associated with a medication.

OpenIssue: This concept domain should be reviewed to determine whether it needs a "ConceptualSpaceForClassCode" property to link to a RIM classCode.

Definition:

A molecular structure (molecule or part of a molecule) which is the part of the molecule causing the intended pharmacological action. The value set for ActiveMoietySubstanceType may often be a subset of a SubstanceType value set. Candidate value sets are subsets of ChEBI, PubChem CID, CAS Number, InChi Key, and UNII.

Examples:

• Metoprolol (without the succinate or tartrate)

• Amoxicillin (anhydrous)

• Heparin (ion, without the matching Na or K cation)

Property:   ConceptualSpaceForClassCode: EntityClass.MMAT

Definition:

Identifies a drug or the use of a drug as produced by a specific manufacturer

OpenIssue: This concept domain should be reviewed to determine whether it needs a "ConceptualSpaceForClassCode" property to link to a RIM classCode.

Definition:

A drug product identified at the level of the package in which it is commonly distributed. Code systems such as UPC (Universal Product Code), NDC (National Drug Code), GTIN(Global Trade Item Number) might be bound to this domain in a given realm.

Definition:

Indicates the material to which the patient was exposed which is believed to be related to the adverse reaction

OpenIssue: This concept domain should be reviewed to determine whether it needs a "ConceptualSpaceForClassCode" property to link to a RIM classCode.

Definition:

Indicates types of allergy and intolerance agents which are non-drugs. (E.g. foods, latex, etc.)

Definition:

An Entity or combination of Entities transformed for a particular purpose by a manufacturing process.

Examples: Processed food products, disposable syringes, chemistry analyzer, saline for infusion

Property:   ConceptualSpaceForClassCode: EntityClass.MMAT

Definition:

A type of manufactured material used in an activity, without being substantially changed through that activity.

Property:   ConceptualSpaceForClassCode: EntityClass.DEV

Definition:

Examples:

• RFID
• WiFi
• Infrared

Property:   ConceptualSpaceForClassCode: EntityClass.DEV

Definition:

Description: Indicates the types of products whose associated records are allowed to be masked.

Property:   ConceptualSpaceForClassCode: EntityClass.MMAT

Definition:

Description: Identifies products such as (1) the GS1 (was UPC and EAN); (2) the U.S., the National Drug Code, which is the U.S. version of what is internationally named the (3) "Medicinal Product Identifier" (MPID). For device products such product code is also known as the "Unique Device Identifier" and may or may not use the GS1 system of product codes. In local contexts the product code can come from local coding systems also, as long as it is a code that denotes to a description of a manufactured product.

Examples:

• 0049-3980-41 (NDC for Geodon Roerig 80 mg capsules 10 capsules x 8 blister packs in a carton)

Property:   ConceptualSpaceForClassCode: EntityClass.MMAT

Definition:

An identifying data string for healthcare products.

Example code sets include Healthcare Common Procedure Coding System (HCPCS) and Universal Product Code (UPC).

Property:   ConceptualSpaceForClassCode: EntityClass.MMAT

Definition:

Definition:A device with direct or indirect therapeutic purpose.

Property:   ConceptualSpaceForClassCode: EntityClass.DEV

Definition:

Description: A type of substance that is used as an ingredient within a product.

Examples:

• Morphine

• wheat germ

• calcium

Property:   ConceptualSpaceForClassCode: EntityClass.MMAT

Definition:

Definition:Materials introduced to a specimen. These additives may be introduced in order to preserve, maintain or enhance the particular nature or component of the specimen.

Examples:

• Ammonium heparin

• Boric Acid

• Phenol

Property:   ConceptualSpaceForClassCode: EntityClass.MAT

Definition:

Description: A specimen is defined as a physical entity that is an individual, a group, an item, or a part representative of a larger group, class or whole that is the target of an observation or analysis for the purpose of drawing conclusions about the group, class, or whole. This can be used to code a component of the specimen that the observation diagnosis relates to. Note that any physical entity in the universe has the potential to become a specimen.

Examples:

• Blood

• Water

• Animal cadaver

Property:   ConceptualSpaceForClassCode: EntityClass.ENT

Definition:

Description: To be used to code the anatomic component of the human-sourced specimen that the lab observation relates to.

Examples:

• Endometrial biopsy

• Thyroid fine needle aspirate

• Urine

Property:   ConceptualSpaceForClassCode: EntityClass.ENT

Definition:

Description: A specimen that is manufactured or a specimen from a manufactured material. This may be a quality control specimen or a manufactured substance.

Examples:

• Quality control specimen

• Aspirin

• Breakfast sausage

Property:   ConceptualSpaceForClassCode: EntityClass.MMAT

Definition:

Definition:

Further classifies entities of EntityClass ORG.

Examples:

• HL7 workgroup

• corporation

• fraternal organization

Property:   ConceptualSpaceForClassCode: EntityClass.ORG

Definition:

A code that is used to indicate the type of organization which is originating and sending the ICSR. The current code example reference is from the International Conference on Harmonisation (ICH) Expert Workgroup guideline on Clinical Safety Data Management: Data Elements for Transmission of Individual Case Safety Reports.

Example concepts are: Pharmaceutical Company, Regulatory Authority, Health Professional, Regional Pharmacovigilence Center, World Health Organization Collaborating Center for International Drug Monitoring.

Property:   ConceptualSpaceForClassCode: EntityClass.ORG

Definition:

The manufacturer of a vaccine.

Property:   ConceptualSpaceForClassCode: EntityClass.ORG

Definition:

A physical place or site with its containing structure. May be natural or man-made. The geographic position of a place may or may not be constant.

Examples: dam; city; state.

Property:   ConceptualSpaceForClassCode: EntityClass.PLC

Definition:

Codes identifying nation states. Allows for finer grained specification of Entity with classcode <= NAT

Example:ISO3166 country codes.

Property:   ConceptualSpaceForClassCode: EntityClass.COUNTRY

Definition:

Description: A territorial entity that may be cited as the body over which an agency exercises jurisdiction, or which defines a sphere in which a party has a particular responsibility.

Examples:

• United States

• New York

• European Union

Property:   ConceptualSpaceForClassCode: EntityClass.PLC

Definition:

Codes to characterize a Resource Group using categories that typify its membership and/or function

.

Example: PractitionerGroup

Property:   ConceptualSpaceForClassCode: EntityClass.RGRP

Definition:

EntityDeterminer in natural language grammar is the class of words that comprises articles, demonstrative pronouns, and quantifiers. In the RIM, determiner is a structural code in the Entity class to distinguish whether any given Entity object stands for some, any one, or a specific thing.

Definition:

Special handling requirements for an Entity.

Example:Keep at room temperature; Keep frozen below 0 C; Keep in a dry environment; Keep upright, do not turn upside down.