A_AdministerMedicationCourse - tabular view

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UKCT_RM140700UK01
AdministerMedicationCourse

A CMET describing the administration of a course of medication.  It covers courses of any duration, including those that only consist of  a single dose

Used by:
[1..1] classCode (CS {CNE:SBADM} ){ Fixed="SBADM " }

Indicates that this is a substance administration act.

  • Fixed value: "SBADM"
[1..1] moodCode (CS {CNE:EVN} ){ Fixed="EVN " }

The mood code of the  substance administration act. It indicates that the administration is in progress or ended.

  • Fixed value: "EVN"
[1..2] id (LIST<II>)

The first identifier is mandatory and is the unique national identifier for this instance of a specific clinical statement. The second identifier carries a local identifier allocated by the source system.

The Identifier Global datatype flavour is used to carry the first identifier as follows:

  • The root attribute shall contain a DCE UUID

The Identifier External datatype flavour is used to carry the second identifier as follows:

  • The root carries an OID for the local identifier scheme
  • The extension carries a human-readable identifier from that scheme
[1..1] code (CD {CNE:AdministrationSnCT} )

One or more SnomedCT code identifying the act as describing the administration of a course of medication. 

The Concept Descriptor (CD) dataype shall be used to carry this information as follows:

  • The code attribute shall contain a code from the relevant vocabulary
  • The code System attribute shall contain the OID for SnomedCT
  • The display text shall carry a description associated with the code in SnomedCT
  • the original text attribute may be used if required
  • qualifier(s) may be used if required.
[1..1] statusCode (CS {CNE:ActStatus} )

The mandatory status of the medication administration act.

The Coded Only datatype flavour is used to carry this information. The code attribute will contain one of thefollowing values from the list of codes in theHL7  Act Status vocabulary: 

  • cancelled - the administration will not be performed
  • aborted  - the  administration has been started, then stopped with no intention to complete it.
  • active - administration is in progress, and is intended to be completed
  • suspended - the administration has been suspended after starting it. It may or may not be restarted
  • completed - the administration has been completed.
[0..1] effectiveTime (IVL<TS>)

The time at which, or period during which, the dose was administered.

[0..1] activityTime (IVL<TS>)

Not to be used in this instance.

[0..1] availabilityTime (TS)

The time at which the statement was committed on the original system that recorded it.

[0..*] performer

An optional participation of the agent(s) / person(s) / device(s) performing the administration.  At least one SHALL be supplied if it is not inherited by context conduction.

[1..1] typeCode (CS {CNE:PRF} ){ Fixed="PRF " }

Indicates the role of primary performer.

  • Fixed value: "PRF"
[1..1] contextControlCode (CS {CNE:ContextControl} )

A code that specifies how this Participation contributes to the context of the current Act, and whether it may be propagated to descendent Acts whose association allows such propagation.

  • Default value: "OP" - Overriding and propagating

"The default value of OP" indicates that the association overrides the existing context associated with the Act, and will propagate to any descendant Acts reached by conducting Act Relationships.

[1..1] time (IVL<TS>)

The time atwhich the performer participated in the performance.

[1..1] role (RoleChoice)

The agent / device / person performing this participation.

[0..1] author

An optional participarttion of the agent / device / person who authored this medication statement.  It must be present if it is not inherited via context conduction.

[1..1] typeCode (CS {CNE:AUT} ){ Fixed="AUT " }

Indicates that the role is the author

  • Fixed value: "AUT"
[1..1] contextControlCode (CS {CNE:OP} ){ Fixed="OP " }

A code that specifies how this Participation contributes to the context of the current Act, and whether it may be propagated to descendent Acts whose association allows such propagation.

The value of contextControlCode should be set appropriately according to the context of the participation being modelled.

  • Fixed value: "OP" - Overriding and propagating

The fixed value of "OP" indicates that the association overrides the existing context associated with the Act, and will propagate to any descendant Acts reached by conducting ActRelationships.

[1..1] time (TS)

The time of the author's participation - optional.

[1..1] role (RoleChoice)

The agent / device / person performing this participation.

[0..1] location

A participation representing the location at which the course was administered.

[1..1] typeCode (CS {CNE:LOC} ){ Fixed="LOC " }

Indicates that this a location participation.

Fixed value:= "LOC"

[1..1] contextControlCode (CS {CNE:OP} ){ Fixed="OP " }

A code that specifies how this Participation contributes to the context of the current Act, and whether it may be propagated to descendent Acts whose association allows such propagation.

The value of contextControlCode should be set appropriately according to the context of the participation being modelled.

  • Fixed value: "OP" - Overriding and propagating

The fixed value of "OP" indicates that the association overrides the existing context associated with the Act, and will propagate to any descendant Acts reached by conducting ActRelationships.

[1..1] role (ActLocation)

The choice containing the location.

[1..1] consumable
The mandatory participation of the manufactured product that was administered to the patient.
[1..1] typeCode (CS {CNE:CSM} ){ Fixed="CSM " }

Indicates that the role is that of a consumable

  • Fixed value: "CSM"
[1..1] contextControlCode (CS {CNE:ContextControl} )

A code that specifies how this Participation contributes to the context of the current Act, and whether it may be propagated to descendent Acts whose association allows such propagation.

The value of contextControlCode should be set appropriately according to the context of the participation being modelled.

  • Fixed value: "OP" - Overriding and propagating

The fixed value of "OP" indicates that the association overrides the existing context associated with the Act, and will propagate to any descendant Acts reached by conducting ActRelationships.

[1..1] manufacturedProduct (ManufacturedProduct)
[0..1] informant
The optional participation of who or what informed the author about this medication administration.
[1..1] typeCode (CS {CNE:INF} ){ Fixed="INF " }

Indicates the role of informant.

  • Fixed value: "INF"
[1..1] contextControlCode (CS {CNE:ContextControl} )

A code that specifies how this Participation contributes to the context of the current Act, and whether it may be propagated to descendent Acts whose association allows such propagation.

The value of contextControlCode should be set appropriately according to the context of the participation being modelled.

  • Default value: "OP" - Overriding and propagating

The default value of "OP" indicates that the association overrides the existing context associated with the Act, and will propagate to any descendant Acts reached by conducting ActRelationships.

[1..1] time (IVL<TS>)

The time at which the informant provided the information.

[1..1] role (RoleChoice)

The agent / device / person performing this participation.

[0..*] participant

An optional participation to any other participant not explicitly catered for elsewhere in this CMET.

[1..1] typeCode (CS {CNE:ParticipationType} )

Indicates the nature of the participation. It shall contain a value taken from the HL7 ParticipationType vocabulary.

[1..1] contextControlCode (CS {CNE:ContextControl} )

A code that specifies how this Participation contributes to the context of the current Act, and whether it may be propagated to descendent Acts whose association allows such propagation.

The value of contextControlCode should be set appropriately according to the context of the participation being modelled.

  • Fixed value: "OP" - Overriding and propagating

The fixed value of "OP" indicates that the association overrides the existing context associated with the Act, and will propagate to any descendant Acts reached by conducting ActRelationships.

[1..1] time (IVL<TS>)

The time at which the participant was involved in the activity.

[1..1] agent      [CMET: UKCT_MT120101UK04]

The agent acting as the participant. It shall be a person   / organisation / device, and be known or not known to NPfIT SDS.

[1..1] pertinentInformation
An  relationship to an Act carrying  details of the administation type.
[1..1] typeCode (CS {CNE:PERT} ){ Fixed="PERT " }

Indicates that this is a pertinent information relationship.

  • Fixed value:= "PERT"
[1..1] contextConductionInd (BL)

If true, associations in the parent act are conducted across the Act Relationship to the child act.

In this context the contextConductionInd defaults to "true".

[1..1] seperatableInd (BL)

This attribute indicates whether or not the source Act is intended to be interpreted independently of the target Act.

If the source act is intended to be interpreted independently the value shall be 'true' otherwise the value shall be 'false'.

The value of seperatableInd shall be evaluated for each usage of the pertinentInformation relationship.

In this context the seperatableInd is fixed as  "false".

[1..1] pertinentAdministrationDetails (AdministrationDetails)

The related AdditionalAdministrationDetails.

[1..1] pertinentInformation2
An  relationship to an Act carrying  details of the administation type.
[1..1] typeCode (CS {CNE:PERT} ){ Fixed="PERT " }

Indicates pertinent information.

  • Fixed value: "PERT"
[1..1] contextConductionInd (BL)

If true, associations in the parent act are conducted across the Act Relationship to the child act.

In this context the contextConductionInd is fixed at "true".

[1..1] seperatableInd (BL)

This attribute indicates whether or not the source Act is intended to be interpreted independently of the target Act.

If the source act is intended to be interpreted independently the value shall be 'true' otherwise the value shall be 'false'.

The value of seperatableInd shall be evaluated for each usage of the pertinentInformation relationship.

In this context the seperatableInd is fixed at "false".

[1..1] pertinentAdministrationType (AdministrationType)

The related administration type.

[0..1] pertinentInformation1
A  relationship to an Act carrying  details of the reason supporting information.
[1..1] typeCode (CS {CNE:PERT} ){ Fixed="PERT " }

Indicates pertinent information.

  • Fixed value: "PERT"
[1..1] contextConductionInd (BL)

If true, associations in the parent act are conducted across the Act Relationship to the child act.

In this context the contextConductionInd is fixed at "true".

[1..1] seperatableInd (BL)

This attribute indicates whether or not the source Act is intended to be interpreted independently of the target Act.

If the source act is intended to be interpreted independently the value shall be 'true' otherwise the value shall be 'false'.

The value of seperatableInd shall be evaluated for each usage of the pertinentInformation relationship.

In this context the seperatableInd is fixed at "false".

[1..1] pertinentReasonSupportingInfo (ReasonSupportingInfo)

Information supporting the reason

[1..1] inFulfillmentOf
A relationship to the planned / requested administration that stimulated this medication dose administration.
[1..1] typeCode (CS {CNE:FLFS} ){ Fixed="FLFS " }

Indicates an 'in fulfilment of ' relationship.

  • Fixed value: "FLFS"
[1..1] inversionInd (BL)

An indicator specifying that the ActRelationship.typeCode should be interpreted as if the roles of the source and target Acts were reversed. The inversion indicator is used when the meaning of ActRelationship.typeCode must be reversed.

The default for inversionInd is "false" indicating that the meaning of ActRelationship.typeCode is not reversed.

[1..1] negationInd (BL)

If true, indicates that the specified participation did not, is not or should not occur (depending on mood).

In this case the negationInd defaults to "false"

[1..1] seperatableInd (BL)

This attribute indicates whether or not the source Act is intended to be interpreted independently of the target Act.

If the source act is intended to be interpreted independently the value shall be 'true' otherwise the value shall be 'false'.

The value of seperatableInd shall be evaluated for each usage of the pertinentInformation relationship.

In this context the seperatableInd defaults to "true".

[1..1] templateId (II)

An identifier of the Act Relationship that supports the linkage of clinical statements using the "Direct Relationship" mechanism.

The Identifier External datatype flavour is used to carry this information as follows:

  • The root attribute shall contain  the OID "2.16.840.1.113883.2.1.3.2.4.18.2"
  • The extension shall contain the fixed template ID
    "CSAB_RM-NPfITUK10.sourceOf1
[1..1] priorMedicationAdministrationRef (MedicationAdministrationRef)

The plan / request that stimulated this medication dose administration.

[0..*] reason
A relationship to the optional reason(s) why the administration of this medication course was not completed.  This should be supplied if the statusCode of the parent AdministerMedication act is cancelled / aborted / suspended
[1..1] typeCode (CS {CNE:RSON} ){ Fixed="RSON " }

Indicates a 'reason' relationship.

  • Fixed value: "RSON"
[1..1] inversionInd (BL)

An indicator specifying that the ActRelationship.typeCode should be interpreted as if the roles of the source and target Acts were reversed. The inversion indicator is used when the meaning of ActRelationship.typeCode must be reversed.

The inversionInd is fixed at "false" indicating that the meaning of ActRelationship.typeCode is not reversed.

[0..1] contextConductionInd (BL)

This field SHALL present if this is a relationship to an act, and SHALL NOT be present if it is to a reference to an Act.  In the first case the template idenifier will be "CSAB_RM-NPfITUK10.sourceOf2", and in the second case "CSAB_RM-NPfITUK10.sourceOf1".

If present, it has a fixed value of "true", i.e.associations in the parent act are conducted across the Act Relationship to the child act.

[0..1] sequenceNumber (INT)

An optional integer specifying the relative ordering of this relationship among other like-types relationships having the same source Act.

[1..1] negationInd (BL)

If true, indicates that the specified participation did not, is not or should not occur (depending on mood).

In this case the negationInd is fixed at "false"

[1..1] seperatableInd (BL)

This attribute indicates whether or not the source Act is intended to be interpreted independently of the target Act.

If the source act is intended to be interpreted independently the value shall be 'true' otherwise the value shall be 'false'.The value of seperatableInd shall be evaluated for each usage of the pertinentInformation relationship.

In this context the seperatableInd is fixed at "false".

[1..1] templateId (II)

An identifier of the Act Relationship that supports the linkage of clinical statements using the "Direct Relationship" or "Reference" mechanism.

The Identifier External datatype flavour is used to carry this information as follows:

  • The root attribute shall contain  the OID "2.16.840.1.113883.2.1.3.2.4.18.2"
  • The extension shall contain the fixed template ID "CSAB_RM-NPfITUK10.sourceOf1" if the relationship points to an Act reference, and "CSAB_RM-NPfITUK10.sourceOf2" if the relationship points to an Act.
[1..1] target (ReasonChoice)

The choice of act / act ref that is acting as the reason .

[0..*] sourceOf

An optional link to a reference to another clinical statement.  The clinical statement may be in the message instance carrying the reference, or on PSIS.

[1..1] typeCode (CS {CNE:ActRelationshipType} )

A code specifying the nature of the link.

The CodedOnly datatype flavour is used to carry this information as follows:

  • The code attribute will contain a value from the list of codes in the ActRelationshipType vocabulary
[1..1] inversionInd (BL)

An indicator specifying that the ActRelationship.typeCode should be interpreted as if the roles of the source and target Acts were reversed. The inversion indicator is used when the meaning of ActRelationship.typeCode must be reversed.

The inversionInd defaults to "false" indicating that the meaning of ActRelationship.typeCode is not reversed.

[0..1] sequenceNumber (INT)

An integer specifying the relative ordering of this relationship among other like-types relationships having the same source Act.

[1..1] negationInd (BL)

If true, indicates that the specified participation did not, is not or should not occur (depending on mood).

In this context the negationInd defaults to "false".

[1..1] seperatableInd (BL)

This attribute indicates whether or not the source Act is intended to be interpreted independently of the target Act.

If the source act is intended to be interpreted independently the value shall be 'true' otherwise the value shall be 'false'.

The value of seperatableInd shall be evaluated for each usage of the pertinentInformation relationship.

In this context the seperatableInd defaults to "true".

[1..1] templateId (II)

An identifier of the Act Relationship that supports the linkage of clinical statements using the "Reference" mechanism.

The Identifier External datatype flavour is used to carry this information as follows:

  • The root attribute shall contain  the OID "2.16.840.1.113883.2.1.3.2.4.18.2"
  • The extension shall contain the template ID "CSAB_RM-NPfITUK10.sourceOf1".
[1..1] target (ActRef)

The clinical statement being referred to.

RoleChoice

The agent / device / person performing this participation.

Used by: AdministerMedicationCourse, AdministerMedicationCourse, AdministerMedicationCourse
[1..1] either : NonAgentRole

The agent / device / person performing this participation.

             ... or ... : UKCT_MT120601UK02

A CMET describing a device participant known to NPfIT SDS.

             ... or ... : UKCT_MT120201UK03

A CMET describing a healthcare professional participant known to NPfIT SDS

RoleChoice
Used by: AdministerMedicationCourse, AdministerMedicationCourse, AdministerMedicationCourse
ActLocation

The location at which this administration was performed..

Used by: AdministerMedicationCourse
[1..1] either : IncidentalLocation

A location which is not related to an organisation known to NPfIT SDS

             ... or ... : UKCT_MT120501UK03

A CMET describing an organisation known to NPfIT SDS.

ManufacturedProduct

The role that plays the manufactured product.

Used by: AdministerMedicationCourse
[1..1] classCode (CS {CNE:MANU} ){ Fixed="MANU " }

Indicates a role scoped by a manufacturer.

  • Fixed value: "MANU"
[1..1] manufacturedManufacturedMaterial (ManufacturedMaterial)

Information about the manufactured material that is the medication being administered

RoleChoice
Used by: AdministerMedicationCourse, AdministerMedicationCourse, AdministerMedicationCourse
AdministrationDetails

Timing & other information about the administration of the course.

Used by: AdministerMedicationCourse
[1..1] classCode (CS {CNE:OBS} ){ Fixed="OBS " }

Indicates that is class describes an observation.

  • Fixed value:= "OBS"
[1..1] moodCode (CS {CNE:EVN} ){ Fixed="EVN " }

Mood code indicating that this observation has been made.

  • Fixed value:="EVN"
[1..1] code (CV {CNE:PrescriptionAnnotation} )

A code from the Prescription Annotation vocabulary indicating that this is administration detail information. 

The Concept Value (CV) dataype shall be used to carry this information as follows:

  • The code attribute shall contain a fixed value of "AD"
  • The code System attribute shall contain the OID for the vocabulary concerned. 
[1..1] value (ST)

Timing and other information about the administration, in textual form.

AdministrationType

Indicates whether the administration being described is of a dose, cycle or course.

Used by: AdministerMedicationCourse
[1..1] classCode (CS {CNE:OBS} ){ Fixed="OBS " }

Indicates that is class describes an observation.

  • Fixed value:= "OBS"
[1..1] moodCode (CS {CNE:EVN} ){ Fixed="EVN " }

Mood code indicating that this observation has been made.

  • Fixed value:="EVN"
[1..1] code (CV {CNE:PrescriptionAnnotation} )

A code from the Prescription Annotation vocabulary indicating that this is administration type information. 

The Concept Value (CV) dataype shall be used to carry this information as follows:

  • The code attribute shall contain a fixed value of "AT"
  • The code System attribute shall contain the OID for the vocabulary concerned. 
[1..1] value (CV {CNE:AdministrationType} )

The administration type in coded form, indicating that this is about the administration of a course of medication.

The Concept Value (CV) dataype shall be used to carry this information as follows:

  • The code attribute shall contain a fixed value of "CO"
  • The code System attribute shall contain the OID for the vocabulary concerned. 
ReasonSupportingInfo

A textual representation of the reason(s) formaking this medication recommendation.

Used by: AdministerMedicationCourse
[1..1] classCode (CS {CNE:OBS} ){ Fixed="OBS " }

Indicates that is class describes an observation.

  • Fixed value:= "OBS"
[1..1] moodCode (CS {CNE:EVN} ){ Fixed="EVN " }

Mood code indicating that this observation has been made.

  • Fixed value:="EVN"
[1..1] code (CV {CNE:ReasonFor} )

A value from the ReasonFor vocabulary indicating that this provides information about the reason for the  medication administration not being completed...

The Concept Value (CV) dataype shall be used to carry this information as follows:

  • The code attribute shall contain a fixed value of "RNCMA"
  • The code System attribute shall contain the OID for the vocabulary concerned. 
[1..1] value (ST)

A string containing the reason.

MedicationAdministrationRef

The RequestMedicationAdministration / PlanMedicationAdministration that this dose administration is fulfilling.

Used by: AdministerMedicationCourse
[1..1] classCode (CS {CNE:SBADM} ){ Fixed="SBADM " }

Indicates that this is a substance administration act.

  • Fixed value: "SBADM"
[1..1] moodCode (CS {CNE:RQO} ){ Fixed="RQO " }

The mood code of the referenced act.  It will be "INT" if it is a Plan MedicationAdministration or "RQO" if it is a RequestMedicationAdministration.

[1..1] id (II)

The unique national identifier for this instance of the clinical statement being referred to. 

The Identifier Global datatype flavour is used to carry the identifier as follows:

  • The root attribute shall contain a DCE UUID
ReasonChoice

A choice of a reason / reference to a reason why this dose administration was not completed.

Used by: AdministerMedicationCourse
[1..1] either : Observation

An observation acting as a reason

             ... or ... : ReasonForNonCompletionRef

A reference to any sort of act acting as the reason.

ActRef

A reference to any other clnical statement.

Used by: AdministerMedicationCourse
[1..1] classCode (CS {CNE:ACT} ){ Fixed="ACT " }

The class of the Act being referenced.  It shall contain a value from the HL7 ActClass vocabulary.

[1..1] moodCode (CS {CNE:ActMood} )

The mood code of the Act being referenced. It shall contain a value from the HL7 ActMood vocabulary.

[1..1] id (II)

The unique national identifier for this instance of the clinical statement being referred to. 

The Identifier Global datatype flavour is used to carry the identifier as follows:

  • The root attribute shall contain a DCE UUID
NonAgentRole

A role played by a person who is not an agent  (i.e. a care professional).

Used by: AdministerMedicationCourse, RoleChoice, AdministerMedicationCourse, AdministerMedicationCourse
[1..1] classCode (CS {CNE:ROL} ){ Fixed="ROL " }

Indicates this is a role.

  • Fixed value: "ROL"
[0..1] id (II)

An optional unique identifier of the role-player.  May be used to convey the NHS number of a patient who is playing a role.  It shall be comprise an OID for the identification scheme and the identifier within that scheme (e.g. for patient NHS number.

[1..1] code (CV {CNE:PersonRelationshipType} )

A code identifying the relationship of the non-agent person to the patient, e.g. parent  or carer.

The Coded  Plain flavour of the Coded Value (CV) datatype shall be used to carry this information as follows:

  • The code attribute shall contain a value from the list of codes in the  vocabulary
  • The code System attribute shall contain the OID for the vocabulary
  • The display text attribute will carry a description for the code from the vocabulary.
[0..1] playingNonAgentPerson (NonAgentPerson)

An optional link to the person palying the non-agent role.

IncidentalLocation

A location which is not related to an organisation known to NPfIT SDS

Used by: AdministerMedicationCourse, ActLocation
[1..1] classCode (CS {CNE:ISDLOC} ){ Fixed="ISDLOC " }

Indicates that this is an incidental service deklivery location.

Fixed value:= "ISDLOC"

[1..1] code (CV {CNE:LocationTypeSnCT} )

This indicates the type of the location, represented using a SnomedCT code.

The Coded Plain flavour of the CV dataype shall be used to carry this information as follows:

  • The code attribute shall contain a code from the relevant vocabulary
  • The code System attribute shall contain the OID for SnomedCT
  • The display text shall carry a description associated with the code in SnomedCT
[0..1] location (Place)
ManufacturedMaterial
The type of medication being administered
Used by: ManufacturedProduct
[1..1] classCode (CS {CNE:MMAT} ){ Fixed="MMAT " }

Indicates that this is a manufactured material.

  • Fixed value: "MMAT"
[1..1] determinerCode (CS {CNE:EntityDeterminer} )

The determiner code of the entity.

The value of determinerCode should be set according to the specification of the drug being carried in the entity. 

The CodedOnly datatype flavour is used to carry this information as follows:

  • The code attribute will contain a value from the list of codes in the EntityDeterminer vocabulary;
[1..1] code (CE {CNE:ManufacturedMaterialSnCT} )

The type of drug being administered in SnomedCT coded form.

The drug can be identified by an actual product description and can describe either a product or a product pack. The coded form shall include the formulation and strength.

The Coded with Equivalents (CE) datatype shall be used to carry this information as follows:

  • The code attribute shall contain a value from the list of codes in the vocabulary
  • The code System attribute shall contain the OID for SnomedCT
  • the displayText shall contain a description for the code from the coding system
  • the original text attribute may be used if required
  • the translation attribute shall not be used.

NOTE: this attribute was intended to use the CD dataype, but HL7 tooling issues make this impossible. 

[0..1] lotNumberText (ST)

The optional batch number of the material administered.

Observation

An observation acting as a reason for the administration being in its current state.

Used by: AdministerMedicationCourse, ReasonChoice
[1..1] classCode (CS {CNE:OBS} ){ Fixed="OBS " }

Indicates that is class describes an observation.

  • Fixed value:= "OBS"
[1..1] moodCode (CS {CNE:EVN} ){ Fixed="EVN " }

Mood code indicating that this observation has been made.

  • Fixed value:="EVN"
[1..2] id (LIST<II>)

 set of unique identifiers for this instance of an observation.

The first is mandatory and is a unique identifier for this instance of a specific clinical statement. The second is optional and allows an observation to be identified by a local identifier.

The Identifier Global datatype flavour is used to carry the first identifier as follows:

  • The root attribute shall contain a DCE UUID

The Identifier External datatype flavour is used to carry the second identifier as follows:

  • The root carries an OID for the local identifier scheme
  • The extension carries a human-readable identifier from that scheme.
[1..1] code (CD {CNE:ObservationTypeSnCT} )

One or more SnomedCT code identifying the kind of observation made about the patient.

The Concept Descriptor (CD) dataype shall be used to carry this information as follows:

  • The code attribute shall contain a code from the relevant vocabulary
  • The code System attribute shall contain the OID for SnomedCT
  • The display text shall carry a description associated with the code in SnomedCT
  • the original text attribute may be used if required
  • qualifier(s) may be used if required.
  • For each clinical statement that is an observation the usage of Observation.code is described below:
    • Patient Legal Status - the informal or Mental Health Act Section current at the time the message is created.
    • Living Will - The description of a living will in coded format.
    • Preferred Written Communication Requirements -  the patient's special requirements for written communication. 
    • Religious/Culturally Dependent Needs - a  patient's religious/cultural needs. 
    • Health & Social Issue as described by HCP - a type of issue, it's severity and status as identified by an HCP.
    • Health & Social Issue as described by patient - a type of issue, it's severity and status as identified by the patient.
    • Attitude of carer to issue - the carer's attitude to the issue.
    • Patient awareness of issue - the patient's awareness of the issue.
    • Carer awareness of issue - the carer's awareness of the issue.
    • Diagnosis - a diagnosis including certainty of diagnosis and negation.
    • Prognosis - a prognosis associated with a diagnosis.
    • Finding - a finding including any additional descriptions that can be coded.
    • Outcome - an outcome.
    • Goal - a goal identified for the future.
    • Family History - family history item, including description of relationship of person with family history to patient.
    • Risk Statement - an identified risk to others from the patient.
    • Risk Incident - the actual risk in a risk incident.
    • Smoking - the current status of the smoking habits of the patient including smoking consumption.
    • Smoking future intentions - the patient's future intentions to change smoking habits.
    • Alcohol - the alcohol status of the patient at the time of recording, includes alcohol consumption.
    • Alcohol future intentions - the patient's future intentions with regard to alcohol consumption.
    • Substance misuse - a known drug habit.
    • Exercise - the exercise habits of the patient.
    • Occupation - the patient's occupation .
    • Employment - information on the employment status of a patient Housing - information on the housing situation of the patient in coded form.
    • Social Network - the nature of the social network of the patient. Religion - information about the patient's religion.
    • Ethnic Category - information about the patient's ethnic category . 
    • Services - a type of service being provided by other agents to the patient.
    • Care provided by Carer - the nature of care provided by the carer to the patient.
    • Functioning and wellbeing - the functioning and wellbeing of the patient.
[1..1] statusCode (CS {CNE:ActStatus} )

The status of the observation.  It shall be a value taken from the HL7ActStatus vocabulary.

[1..1] effectiveTime (GTS)

Optional - not to be used in P1R2.

[0..1] activityTime (IVL<TS>)

The date and time the observation was made.

For each observation which has a requirement to carry the activity date and time the usage of Observation.activityTime is described below:

  • Health & Social Issue as described by HCP - The date and time that the problem was identified by the HCP - optional.
  • Prognosis - The date and time that the HCP made a diagnosis associated prognosis.
  • Family History - The date of stating the family history finding.
[0..1] availabilityTime (TS)

The time at which this observation was first recorded on a computer system.

[0..1] value (ANY)

A value associated with this observation, including any units involved.

ReasonForNonCompletionRef

A reference to an Act which is a reason why this medication administration request was not completed.

Used by: AdministerMedicationCourse, ReasonChoice
[1..1] classCode (CS {CNE:ACT} ){ Fixed="ACT " }

The class of the Act being referenced.  It shall contain a value from the HL7 ActClass vocabulary.

[1..1] moodCode (CS {CNE:ActMood} )

The mood code of the Act being referenced. It shall contain a value from the HL7 ActMood vocabulary.

[1..1] id (II)

The unique national identifier for this instance of the clinical statement being referred to. 

The Identifier Global datatype flavour is used to carry the identifier as follows:

  • The root attribute shall contain a DCE UUID
NonAgentPerson

Someone who is not known to the NPfIT SDS.

Used by: NonAgentRole
[1..1] classCode (CS {CNE:PSN} ){ Fixed="PSN " }

Indicates that the entity is a person

  • Fixed value: "PSN"
[1..1] determinerCode (CS {CNE:INSTANCE} ){ Fixed="INSTANCE " }

Indicates that the entity is a single identifiable person.

  • Fixed value: "INSTANCE"
[1..1] name (PN)

The name of the person

Place

An entity describing a place that is not an organisation recognised by SDS.  If Place is used, at least one of the non-structural attributes SHALL be used. 

Used by: IncidentalLocation
[1..1] classCode (CS {CNE:PLC} ){ Fixed="PLC " }

Indicates that the entity is a place

  • Fixed value: "PLC"
[1..1] determinerCode (CS {CNE:INSTANCE} ){ Fixed="INSTANCE " }

Indicates that the entity is a single identifiable place

  • Fixed value: "INSTANCE"
[0..1] name (TN)

The optional name of the place

[0..1] telecom (TEL)

An optional telecom contact for the place

[0..1] addr (AD)

An optional address of the place

[0..1] positionText (ED)

An optional grid reference. It may be as precise as required.

[0..1] gpsText (ST)

An optional GPS reference.  It may be as precise as required.