Clinical Statement Choice - tabular view

No Current Link To VocabularyCoded With ExtensionsCoded No Extensions
UKCT_RM140900UK01
ClinicalStatementChoice

A choice of clinical statements that are present in a discharge.

Used by: ClinicalStatementChoice, Organizer
[0..1] subject

Refers to the  subject where the subject is not the patient who is the target of the record.

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

Indicates that this is a subject.

  • Fixed value : "SBJ"
[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  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 Act Relationships.

[1..1] subjectRole (SubjectRole)

The person who is the subject.

[0..*] performer
Refers to a performer of an activity conveyed in a clinical statement.
The following participations are modelled using the performer participation:
Assessor of Diagnosis - optional
Performer of Procedure - optional
Performer of future care event - optional
[1..1] typeCode (CS {CNE:PRF} ){ Fixed="PRF " }

Indicates that this is a 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.

The value of  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 Act Relationships.

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

The time during / at which the performer participated in the act described by the clinical statement.

[1..1] role (RoleChoice)

The choice of device / agent / non-agent performing this participation.

[0..1] author

Refers to the person or department responsible for signing the clinical data conveyed in a clinical statement.

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

Indicates that the role is that of 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  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 adds to the existing context associated with the Act, and will propagate to any descendant Acts reached by conducting Act Relationships.

[1..1] time (TS)

The participation time of the author.

[1..1] role (RoleChoice)
The agent / device / non-agent performing this particpation.
[0..1] location

Refers to the choice of location relevant to clinical data conveyed in a clinical statement.

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

Indicates that this is a location.

  • 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  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 adds to the existing context associated with the Act, and will propagate to any descendant Acts reached by conducting Act Relationships.

[1..1] role (ActLocation)

The choice of location.

[0..*] informant
Refers to the agent / person / device acting in the role of informant.  The patient may at as an informant.
[1..1] typeCode (CS {CNE:INF} ){ Fixed="INF " }

Indicates that the role is that 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  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 Act Relationships.

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

The time during / at which the informant participated in the act described by the clinical statement.

[1..1] role (RoleChoice)

A choice containing the agent / person / device acting as the informant.

[0..*] participant

Refers to a participant in clinical events.

The following participants are modelled using this participation:

Care Event Service Provider Organisation - optional

Care Event HCP - required  

HCP assisting the Procedure - optional

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

Indicates the type of participation. The most appropriate value for the context shall be selected from the vocabulary.

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

  • The code attribute will contain a value from the list of codes in the Participation Type 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  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 adds to 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 of the participation.

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

A link to the agent CMET UKCT_MT120101UK04

[0..*] pertinentInformation4

Refers to a participant in clinical events.

The following participants are modelled using this participation:

Care Event Service Provider Organisation - optional

Care Event HCP - required  

HCP assisting the Procedure - optional

[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 ActRelationship to the child act.

In this context the contextConductionInd defaults to "true".

[0..1] sequenceNumber (INT)

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

[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] pertinentSupportingInfo (SupportingInfo)

A code and/or effective time and/or text and/or value that is pertinent to the clinical statement

[0..*] pertinentInformation5

Refers to medication information that is pertinent to a clinical statement associated with the acute care spell.

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

Indicates that this is pertinent information.

  • Fixed value: "PERT" (pertinent information)
[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] contextConductionInd (BL)

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

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

[0..1] sequenceNumber (INT)

An integer specifying the relative ordering of this relationship among other like-type 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 is fixed at "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 template ID "CSAB_RM-NPfITUK10.sourceOf2".
[1..1] pertinentMedicationChoice      [CMET: UKCT_MT141001UK01]

A link to the medication choice CMET.

[0..*] sourceOf2

Refers to a participant in clinical events.

The following participants are modelled using this participation:

Care Event Service Provider Organisation - optional

Care Event HCP - required  

HCP assisting the Procedure - optional

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

[1..1] contextConductionInd (BL)

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

In this context the contextConductionInd defaults to "true".

[0..1] sequenceNumber (INT)

An optional integer specifying the relative ordering of this relationship among other like-type 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 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" 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.sourceOf2".
[1..1] target (ClinicalStatementChoice)

A reference to the target clinical statement that is being linked to the source clinical statement. The target clinical statement is included in the message in it's entirety.

[0..*] sourceOf1

A relationship to another clinical statement by reference.  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 default for inversionInd is "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 is fixed at "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)

A reference to the target clinical statement that is being linked to the source clinical statement. 

[1..1] either : CareEvent

A care event statement present in the discharge.

             ... or ... : Consent
             ... or ... : Observation

An observation statement present in the discharge.

             ... or ... : Organizer

An organizer statement present in the discharge.

             ... or ... : Procedure

A procedure statement present in the discharge.

             ... or ... : StatementRelationship

A relationship statement present in the discharge.

             ... or ... : SubstanceAdministration

A substance administration statement present in the discharge

             ... or ... : Supply

A supply statement present in the discharge.

CareEvent

A clinical statement describing an care event.

There can be zero, one or many care event statements.

Used by: ClinicalStatementChoice, ClinicalStatementChoice, Organizer
[1..1] classCode (CS {CNE:ENC} ){ Fixed="ENC " }

Indicates that the care event is an encounter.

  • Fixed value: "ENC"
[1..1] moodCode (CS {CNE:x_ActMoodIntentEvent} )

The mood code of the Care Event.

The value of mood code should be set according to the information and context of the clinical statement information being carried in the encounter class.  

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 x_ActMoodIntentEvent vocabulary.
[1..2] id (LIST<II>)

A list of unique identifiers for this instance of a care event.

The first is mandatory and is a unique identifier for this instance of a specific clinical statement.  The second is optional and allows a care event 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:InteractionTypeSnCT} )

A SnomedCT code identifying the interaction medium of the Care Event, e.g. face-to-face, telephone.

 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.
[0..1] statusCode (CS {CNE:ActStatus} )

The (optional) status of the CareEvent, e.g. active, suspended, completed.  This must be used if the moodCode of the act is "EVN"

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

  • The code attribute will contain a value from the list of codes in the Act Status vocabulary.
[1..1] effectiveTime (IVL<TS>)

The effective date carries the start and end date/time of the care event. The start date/time is required and the end date/time is optional. 

The date range shall be carried as follows:

If both a start date and an end date are present the Date or Time Interval Complete datatype shall be used:

  • The low attribute shall contain the start date
  • The high attribute shall contain the end date.

If only a start date is present the Date or Time Interval After datatype shall be used:

  • The low attribute shall contain the start date.
[0..1] availabilityTime (TS)

The date and time that the care event was recorded on the source system.

[0..1] pertinentInformation1

Refers to the care event commentary associated a care event.

[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 ActRelationship 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 at "false".

[1..1] pertinentCareEventCommentary (CareEventCommentary)

A link to the care event commentory.

[1..1] pertinentInformation3

Refers to the care setting associated with the care event, e.g. inpatient, outpatient.

[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 ActRelationship 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 at "false".

[1..1] pertinentServiceType (ServiceType)

A link to the service type

[1..1] pertinentInformation2

Refers to the kind of service providing the care event.

[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 ActRelationship 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 at "false".

[1..1] pertinentCareSetting (CareSetting)

A link to the care setting.

Consent

Information about the patient's consent with regard to organ donation, surgery, etc.

Each organ / procedure / etc for which there is a positive consent will be carried in an instance of a Consent act.

There is currently no mechanism for specifying negation of consent.

Used by: ClinicalStatementChoice, ClinicalStatementChoice, Organizer
[1..1] classCode (CS {CNE:CONS} ){ Fixed="CONS " }

Indicates that this is an act of consent.

  • Fixed value: "CONS"
[1..1] moodCode (CS {CNE:x_ActMoodIntentEvent} )

The mood code of the consent act.

The value of mood code should be set appropriately according to the information and context of the consent being modelled.

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 x_ActMoodIntentEvent vocabulary.
[1..2] id (LIST<II>)

A list of unique identifiers for this instance of a consent.

The first is mandatory and is a unique identifier for this instance of a consent. The second is optional and allows a consent statement 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:ConsentSnCT} )

A SnomedCT code identifying the type of the consent, e.g. for a surgical procedure or donation of one or more kind of organ.

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.
[0..1] statusCode (CS {CNE:ActStatus} )

The (optional) status of the consent act, e.g. active, suspended, completed.  This must be used if the moodCode of the act is "EVN"

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

  • The code attribute will contain a value from the list of codes in the Act Status vocabulary.
[1..1] effectiveTime (IVL<TS>)

The period of validity of the consent.

[0..1] activityTime (TS)

The date and time the consent was given.

Observation

Information about a clinical statement that describes an observation.

The following clinical statements are modelled as observation acts:                   

Legal Status

Living will

Preferred Written Communication Requirements

Religious/Culturally Dependent Needs

Health & Social Issue as described by patient

Health & Social Issue as described by HCP

Attitude of patient to issue

Attitude of carer to issue

Patient awareness of issue

Carer awareness of issue

Diagnosis

Prognosis

Findings

Goal

Family History

Allergy

Risk Statement

Risk Incident

Smoking

Smoking Future Intentions

Alcohol

Alcohol future intentions

Substance misuse

Exercise habits

Occupation

Employment

Housing

Social network

Religion

Ethnic category

Services

Carer

Functioning and wellbeing

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

Indicates that this is an observation.

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

The mood code of the observation act.

The value of mood code should be set according to the information and context of the clinical statement information being carried in the observation class. 

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 ActMood vocabulary.
[1..2] id (LIST<II>)

A 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} )

A SnomedCT code identifying the type of observation.

 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.
[0..1] statusCode (CS {CNE:ActStatus} )

The (optional) status of the Observation, e.g. active, suspended, completed.  This must be used if the moodCode of the act is "EVN"

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

  • The code attribute will contain a value from the list of codes in the Act Status vocabulary.
[1..1] effectiveTime (GTS)

The clinically relevant date and time.

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

  • Patient Legal Status - The start and end date of the latest legal status of the patient - optional. 
  • Health & Social Issue as described by patient - The date that the patient noticed the issue and the date that the issue was resolved - optional.
  • Diagnosis - The date and time the diagnosis was true of the patient - optional
  • Finding - the date and time the finding was true of the patient - optional
  • Outcome - The date and time the outcome was assessed - optional.
  • Risk Incident - The date and time that the incident occurred - optional.

A date range shall be carried as follows:

If both a start date and an end date are present the Date or Time Interval Complete datatype shall be used:

  • The low attribute shall contain the start date
  • The high attribute shall contain the end date.

If only a start date is present the Date or Time Interval After datatype shall be used:

  • The low attribute shall contain the start date.

If only an end date is present the Date or Time Interval Before datatype shall be used:

  • The high attribute shall contain the end date.

If the observation occurs more than once, multiple dates / date ranges shall be recorded.

[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 date and time that the observation was recorded on the source system.

[0..1] value (ANY)

The reference range itself, including the units it is expressed in.  It will usually comprise an upper limt and a lower limit.

[0..*] specimen
Refers to a specimen that has been taken from the patient.
[1..1] typeCode (CS {CNE:SPC} ){ Fixed="SPC " }

Indicates that this is a specimen.

  • Fixed value: "SPC"
[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  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 Act Relationships.

[1..1] specimenRole (SpecimenRole)

Information about the role the specimen is playing.

[0..1] referenceRange

Refers to reference ranges for a laboratory result.

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

Indicates that there are reference values.

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

If true, associations in the parent act are conducted across the ActRelationship 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 pertinent Information relationship.

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

[1..1] referenceReferenceValue (ReferenceValue)

A link to the reference value.

Organizer

An organizer contains a collection of related clinical statements.

Used by: ClinicalStatementChoice, ClinicalStatementChoice, Organizer
[1..1] classCode (CS {CNE:ActContainer} )

The class code of the organizer.

The value of class code should be set according to the type of collection of related clinical statements.

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

  • The code attribute will contain a value from the list of codes in the Act Container vocabulary.
[1..1] moodCode (CS {CNE:ActMood} )

The mood code of the organizer.

The value of mood code should be set according to the context of the organizer.

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

  • The code attribute will contain a value from the list of codes in the Act Mood vocabulary.
[1..2] id (LIST<II>)

This allows for two identifiers of an organizer.

The first is mandatory and is a unique identifier for this instance of a specific clinical statement. The second is optional and allows an organizer 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:OrganizerTypeSnCT} )

A SnomedCT code identifying the Organizer type.

 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.
[0..1] statusCode (CS {CNE:ActStatus} )

The (optional) status of the Organizer, e.g. active, suspended, completed.  This must be used if the moodCode of the act is "EVN".

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

  • The code attribute will contain a value from the list of codes in the Act Status vocabulary.
[1..1] effectiveTime (IVL<TS>)

The clinically relevant date and time.

[0..1] availabilityTime (TS)

The date and time that the organizer detail was recorded.

[0..*] specimen

Refers to specimens directly related to the organizer.

[0..*] component

Refers to the clinical statements grouped within an organizer.

This mechanism uses the 'Containment' method of linking clinical statements.

The type of grouping is determined by the value of Organizer. code.  

NOTE: In the P1R2 version of PSIS, any component of an Organizer will not be explicitly indexed, and cannot be progressed in its own right.  For this reason clinically important statements (e.g. medication and allergy statements) must NOT be organizer components in P1R2. 

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

Indicates that this is a component.

  • Fixed value: "COMP"
[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 is not reversed..

[1..1] contextConductionInd (BL)

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

In this context the contextConductionInd defaults to "true".

[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] 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 "false".

[1..1] templateId (II)

An identifier of the Act Relationship that supports the linkage of clinical statements using the "Containment" 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.component".
[1..1] target (ClinicalStatementChoice)

Refers to the choice of all the clinical statements within a discharge.

An organizer clinical statement can contain a minimum of two contained statements of any valid type, including an Organizer.

Procedure

Information about clinical statements that are procedures.

A procedure can either be a procedure that has happened or a procedure that is planned.

Used by: ClinicalStatementChoice, Organizer, ClinicalStatementChoice
[1..1] classCode (CS {CNE:PROC} ){ Fixed="PROC " }

Indicates that this is a procedure.

  • Fixed value: "PROC"
[1..1] moodCode (CS {CNE:x_ActMoodIntentEvent} )

The mood code of the procedure.

The value of mood code should be set according to the information and context of the clinical statement information being carried in the procedure class. The Coded Only datatype flavour is used to carry this information as follows:

  • The code attribute will contain a value from the list of codes in the  vocabulary;
[1..2] id (LIST<II>)

A list of identifiers for this instance of a procedure.

The first is mandatory and is the unique national identifier for this instance of a specific clinical statement. The second is optional and allows a procedure 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:ProcedureTypeSnCT} )

A SnomedCT code identifying the Procedure type.

 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.
[0..1] statusCode (CS {CNE:ActStatus} )

The (optional) status of the Procedure, e.g. active, suspended, completed.  This must be used if the moodCode of the act is "EVN".

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

  • The code attribute will contain a value from the list of codes in the Act Status vocabulary.
[1..1] effectiveTime (IVL<TS>)

The date and time that the patient had the procedure if it has already happened or a future date and time for which a procedure is planned.

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

The date and time that the clinical statement about the procedure was created.

[0..1] availabilityTime (TS)

The date and time that a procedure that has happened was recorded on the source system.

[0..*] product

A reference to something produced by this Procedure, e.g. a specimen or X-ray image.

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

Indicates this is a product

  • Fixed value: "PRD"
[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] specimenRole (SpecimenRole)

A link to the specimen role which is a product of the procedure.

StatementRelationship

The Statement Relationship is a clinical statement that establishes a relationship between two or more clinical statements.

E.g. Cause/Effect - The Statement Relationship states that clinical statement A is the 'cause' of clinical statement B (and conversely that clinical statement B is 'caused by' clinical statement A).

Uses of a relationship statement that have been explicitly identified are defined below:

  • Procedure relationship - An association made between a procedure statement and another clinical statement. E.g. To indicate that a 'finding' is an 'outcome' of a 'procedure'.
  • Finding relationship - An association made between a finding and another clinical statement. E.g. To indicate that a 'finding' is an 'alert' for a second 'finding'.
Used by: ClinicalStatementChoice, Organizer, ClinicalStatementChoice
[1..1] classCode (CS {CNE:OBS} ){ Fixed="OBS " }

Indicates that this is an observation.

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

Indicates that this is an event.

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

A list of unique identifiers for this instance of a relationship statement.

The first is mandatory and is the unique national identifier for this instance of a specific clinical statement. The second is optional and allows a statement relationship 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:RelationshipTypeSnCT} )

 A SnomedCT code identifying the type of the relationship between the two clinical statements being related.

 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] effectiveTime (IVL<TS>)

The date and time that the relationship statement is clinically relevant.

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

An optional date and time that the relationship was established.

[0..1] availabilityTime (TS)

The date and time that the relationship statement was recorded on the source system.

[1..1] pertinentInformation1

A relationship to the subject (statement) of the StatementRelationship. In the relationship "A is the outcome of B", A is the subject.

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

Indicates pertinent information.

  • Fixed value: "PERT"
[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 "true" indicating that the meaning IS 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 negation 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 is fixed at "false".

[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 fixed template ID
    "CSAB_RM-NPfITUK10.sourceOf"
[1..1] pertinentActRef (ActRef)

The statement that is the subject of this relationship

[1..1] pertinentInformation2

A relationship to the object of the StatementRelationship. In the relationship "A is the outcome of B", B is the object.

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

Indicates pertinent information.

  • Fixed value: "PERT"
[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 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 negation 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 is fixed as "false".

[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 fixed template ID
    "CSAB_RM-NPfITUK10.sourceOf"
[1..1] pertinentActRef (ActRef)

The statement that is the object of this relationship

SubstanceAdministration

Information about the administration of substances other than medication.

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

Indicates that this is a substance administration act.

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

The mood code of the substance administration act.

One is mandatory and is a unique identifier for this instance of a specific clinical statement. A second is optional and allows a substance adminisration to be identified by a local identifier. 

The value of mood code should be set according to the information and context of the clinical statement information being carried in the substance administration class.

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

  • The code attribute will contain a value from the list of codes in the  x_DocumentSubstanceMood vocabulary.
[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:SubstanceAdministrationSnCT} )

A SnomedCT code identifying the act as Non-medication Substance Administration..

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.
[0..1] statusCode (CS {CNE:ActStatus} )

The (optional) status of the Substance Administration, e.g. active, suspended, completed.  This must be used if the moodCode of the act is "EVN".

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

  • The code attribute will contain a value from the list of codes in the Act Status vocabulary.
[1..1] effectiveTime (IVL<TS>)

The clinically relevant date and time.

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

The date and time that the activity took place.

[0..1] availabilityTime (TS)

The date and time that the activity was recorded on the source system.

[0..1] doseQuantity (IVL<PQ>)

The quantity of substance used for each administration when it is measured as a dosage.

[0..1] rateQuantity (IVL<PQ>)

An optionale quantity of substance being suppused for each administration when it is measured at a rate of supply.

[0..*] consumable

A reference to the non-medication substance being administered.

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

Indicates that the participation is 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  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 Act Relationships.

[1..1] manufacturedProduct (ManufacturedProduct)

The role of a manufactured product.

Supply

Information about clinical statements that are supply acts.

Used by: ClinicalStatementChoice, Organizer, ClinicalStatementChoice
[1..1] classCode (CS {CNE:SPLY} ){ Fixed="SPLY " }

Indicates that this is a supply act.

  • Fixed value: "SPLY"
[1..1] moodCode (CS {CNE:x_ActMoodIntentEvent} )

The mood code of the supply act.

The value of mood code should be set according to the information and context of the clinical statement information being carried in the supply class as follows:

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

  • The code attribute will contain a value from the list of codes in the  vocabulary;
[1..2] id (LIST<II>)

Unique identifiers for this instance of a supply act.

The first is mandatory and is the unique national identifier for this instance of a specific clinical statement. The  second is optional and allows a supply 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:SupplyActSnCT} )

A SnomedCT code identifying the act as non-medication supply

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.
[0..1] statusCode (CS {CNE:ActStatus} )

The (optional) status of the non-medication Supply act, e.g. active, suspended, completed.  This must be used if the moodCode of the act is "EVN".

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

  • The code attribute will contain a value from the list of codes in the Act Status vocabulary.
[1..1] effectiveTime (IVL<TS>)

The clinically relevant date and time.

If there are repeat issues the date shall be the date the authorisation for the supply expires.

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

The date that the supplystate is attained. eg. date prescription formulated, date prescription authorised, date dispensed, date issued.

[0..1] availabilityTime (TS)

The date time of recording the information.

[0..1] repeatNumber (IVL<INT>)

The number of multiple issues authorised

[0..1] quantity (PQ)

The amount of medication substance supplied. This can include the amount, units, pack quantity and sub pack quantity.

[0..*] product
Refers to the manufactured product.
[1..1] typeCode (CS {CNE:PRD} ){ Fixed="PRD " }

Indicates this is a product

  • Fixed value: "PRD"
[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] manufacturedProduct (ManufacturedProduct)

Details of the manufactured product.

SubjectRole

Refers to the role of subject where the subject (who must be a person) is not the patient who is the target of the record.

Used by: ClinicalStatementChoice
[1..1] classCode (CS {CNE:x_DocumentSubject} )

The class code of the subject role.

The value of class code should be set appropriately according to the information and context of the subject being modelled.

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

  • The code attribute will contain a value from the list of codes in the  vocabulary.
[0..1] id (II)

To provide an optional  identifier of the subject

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

To identify the relationship between patient and subject in coded form.

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 of the vocabulary
  • The display text attribute will carry a description for the code from the vocabulary.

For each clinical statement in which there is a subject participant the usage of  Subject. code is described below:

  • Care Event - A code defining the  relationship between patient and subject of information about a family history issue - optional.
[0..1] documentSubject (SubjectPerson)

The person who is playing the role of subject.

RoleChoice
The agent / device / non-agent performing this particpation.
Used by: ClinicalStatementChoice, ClinicalStatementChoice, ClinicalStatementChoice
[1..1] either : NonAgentRole

The participating person 

             ... or ... : UKCT_MT120601UK02

A CMET identifying the participating device

             ... or ... : UKCT_MT120201UK03

A CMET identifying the agent NPfIT Person

RoleChoice
The agent / device / non-agent performing this particpation.
Used by: ClinicalStatementChoice, ClinicalStatementChoice, ClinicalStatementChoice
ActLocation

The location relevant to the clinical statement.

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

The incidental location.

             ... or ... : UKCT_MT120501UK03

A CMET identifying the organization.

RoleChoice
The agent / device / non-agent performing this particpation.
Used by: ClinicalStatementChoice, ClinicalStatementChoice, ClinicalStatementChoice
SupportingInfo
An Act holding overflow information from the Act acting as the root of the clinical statement.  Supporting information shall not contradict the content of the source act, only add to it or explain it.
Used by: ClinicalStatementChoice
[1..1] classCode (CS {CNE:OBS} ){ Fixed="OBS " }

Indicates that this is an observation. Note that SupportingInfo can be used to supply overflow information for any kind of Act included in the ClinicalStatementChoice, not just Observations.

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

Indicates this is an event.

  • Fixed value: "EVN"
[0..1] code (CV {CNE:SnomedCT} )

A SnomedCT code indicating the nature of the supporting information.

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 SnomedCT
  • The display text attribute will carry a description for the code from the coding system .
[0..1] effectiveTime (IVL<TS>)

A clinically relevant date and time that forms supporting information.

The date range shall be carried as follows:

If both a start date and an end date are present the Date or Time Interval Complete datatype shall be used:

  • The low attribute shall contain the start date
  • The high attribute shall contain the end date.

If only a start date is present the Date or Time Interval After datatype shall be used:

  • The low attribute shall contain the start date.

If only an end date is present the Date or Time Interval Before datatype shall be used:

  • The high attribute shall contain the end date.
[0..1] value (ANY)

A supporting value.

ActRef

Refers to a component using a unique identifier.

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

Indicates this is an act.

  • Fixed value: "ACT"
[1..1] moodCode (CS {CNE:ActMood} )

The mood Code shall take the value of the target act.

[1..1] id (II)

The unique identifier of the target clinical statement.

SubjectPerson

Information about the person who is the subject where the subject is not the patient who is the target of the record.

Used by: SubjectRole
[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)

One or more names of the person who is the subject.

NonAgentRole

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

Used by: ClinicalStatementChoice, RoleChoice, ClinicalStatementChoice, ClinicalStatementChoice
[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 either an OID for the identification scheme and the identifier within that scheme (e.g. for patient NHS number), or a DCE UUID.

[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 playing the non-agent role.

IncidentalLocation
A role played by a location that is not an organisational site.
Used by: ClinicalStatementChoice, ActLocation
[1..1] classCode (CS {CNE:ISDLOC} ){ Fixed="ISDLOC " }

Indicates that the role is a incidental location

  • Fixed value: "ISDLOC"
[1..1] code (CV {CNE:LocationTypeSnCT} )

A SnomedCT code identifying the kind of location being described (e.g. normal residence, ambulance, public place)

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 SnomedCT
  • The display text attribute will carry a description for the code from the coding system .
[0..1] location (Place)

Details of the individual place playing the role of the IncidentialLocation

CareEventCommentary

Commentary accompanying a care event statement.

This class is used to carry additional text which accompanies the information in a clinical statement. It can be used to clarify or support coded information.

The content must not change, contradict or render as ambiguous the coded information.

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

Indicates that this is an observation.

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

Indicates that this is an event.

  • Fixed value: "EVN"
[1..1] value (ST)

 The commentary accompanying a care event.

ServiceType
Refers to the service type that has been provided during the acute care spell
Used by: CareEvent
[1..1] classCode (CS {CNE:OBS} ){ Fixed="OBS " }

Indicates that this is an observation.

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

Indicates that this is an event.

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

A SnomedCT code specifying the service type provided during an acute care spell / care event. 

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 SnomedCT
  • The display text attribute will carry a description for the code from the coding system 
CareSetting

The care setting associated with the acute care spell.

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

Indicates that this is an observation.

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

Indicates that this is an event.

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

A SnomedCT code specifying the care setting..

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 SnomedCT
  • The display text attribute will carry a description for the code from the coding system .
SpecimenRole

Information about the specimen.

Used by: Observation, Procedure
[1..1] classCode (CS {CNE:SPEC} ){ Fixed="SPEC " }

Indicates that this is a specimen.

  • Fixed value: "SPEC"
[1..1] id (II)

Local identifier of a specimen.

The local identifier is carried using the Identifier External datatype flavour as follows:

  • The extension attribute shall contain the local id
  • The root attribute shall contain an OID for the local id. system
[1..1] code (CS {CNE:P} ){ Fixed="P " }

The type of specimen.

  • Fixed value: "P" - taken from the patient
[1..1] specimenMaterial (Material)

Refers to the specimen material.

ReferenceValue

A reference range for a biological measurement, e.g. height, blood haemoglobin.  It may be specific to people of a given sex, age range, etc

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

Indicates that this is an observation.

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

The mood code is fixed as "Criterion"

  • Fixed value: "EVN.CRT"
[0..1] text (ED)

Optional text to explain or otherwise describe the reference range.

[0..1] value (IVL<PQ>)

The reference range itself, including the units it is expressed in.  It will usually comprise an upper limt and a lower limit.

[0..1] interpretationCode (CS {CNE:Interpretation} )

An optional code from the vocabulary named providing an interpretation of the normality of the Observation it applies to.

ManufacturedProduct

The role that plays the manufactured product.

The role is used both by SubstanceAdministration and Supply.

Used by: SubstanceAdministration, Supply
[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.

NonAgentPerson
Details of the non-agent person.
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..*] name (SET<PN>)

The name(s) 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 MUST 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.

Material

Information about the actual specimen taken.

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

Indicates a material.

  • Fixed value: "MAT"
[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 speimen 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;
[0..1] id (II)

An optional identifier of the material.  This attribute may only be used if the determinerCode is "INSTANCE"

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

  • The root attribute shall contain a DCE UUID.
[1..1] code (CE {CNE:SpecimenMaterialTypeSnCT} )

A SnomedCT code identifying the material forming the specimen.

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. 

ManufacturedMaterial

The type of drug being administered or supplied.

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;
[0..1] code (CE {CNE:ManufacturedMaterialSnCT} )

The type of drug being administered or supplied in SnomedCT coded form.

The drug can be identified by a virtual or real product description and can be carried either as a textual product representation or as 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.